Deceased Dog Declaration
If during the year your dog has died and you notify us you may be eligible to a pro rata
refund of your registration fee (from date of notification). Please complete this form and
forward to Masterton District Council, Animal Services, P O Box 444, Masterton 5840 or
email: animalservices@mstn.govt.nz
OWNER DETAILS
Owner’s name:
MDC Owner No:
Owner Date of birth:
Street Address:
Email:
Home Phone:
Mobile Phone:
DOG DETAILS
Name:
Breed:
Tag Number:
Colour:
Age:
Sex:
Name:
Breed:
Tag Number:
Colour:
Age:
Sex:
DECLARATION
I hereby certify that I am the registered dog owner and the above information it true and correct.
(Please note we can impose a penalty for providing a false statement under the Dog Control Act 1996)
Signature of registered owner Date
Credit Dog Account
Credit Rates Account
Property Valuation Number:
Credit Bank Account Number
Please provide a bank deposit slip or printout from your bank. Hand written
account numbers must be written by owners and are provided at owner’s risk.
OFFICE USE ONLY
Refund required:
Yes No
GL: 9030202
Refund Amount:
$
Approved By:
Date Paid:
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