Notication of deceased dog and
application for refund
Please read this first
This form will be scanned by electronic equipment. It is important that you:
use a blue or black pen to complete this form; and
print clearly.
tararua district council
26 gordon street
po box 115
dannevirke 4942
06 374 4080
info@tararuadc.govt.nz
Dog owner details (Please print in CAPITALS)
Title: Mr Mrs Miss Ms
First names
Surname
Postal address
Town Postcode
0
-
0
-
0
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Home phone number Work phone number Mobile phone number
Email
/ /
Owner’s date of birth
Particulars of deceased dog(s)
Dog name Breed Colour Sex Age Tag no. Dog ID
1.
2.
3.
4.
Office use only
NAR
GL code
7502.235.3430
Refund over $10
Amount $
Refund authorised by
Copy to AP incl deposit slip
/ /
Entered into Authority by
Date
/ /
Refund under $10
Amount $
Refund authorised by
Customer signature
Entered into Authority by
Date
/ /
click to sign
signature
click to edit
page 2 of 2 | notification of deceased dog and application for refund
Application for refund
Section 39 of the Dog Control Act 1996 sets out the regualtions for the refund of registration fees.
You will be refunded a part of the registration fee.
The part fee refundable shall be calculated on the basis of the number of complete months remaining in the registration year after
the date of the application for refund (e.g. if you apply for the refund in February, you will be refunded the remaining fee from
March to July).
1. Do you require a refund? Yes No
2
. If you would like the refund direct credited to your bank account, please provide a completed deposit slip and attach it to the
top left at the front of this form.
Declaration
I hereby declare that my dog(s) as listed in ‘Particulars of deceased dog(s)’ have died or have been euthanised and, therefore, I wish
to claim a refund of the registration fees under Section 39 of the Dog Control Act 1996. I understand that making a false declaration
may result in prosecution.
/ /
2 0
Signature of dog owner Date
Office use only
Notes:
click to sign
signature
click to edit
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