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ANIMAL CONTROL 4101 EISENHOWER AVENUE ALEXANDRIA, VIRGINIA 22304 AFFIDAVIT STATEMENT OF ANIMAL CONTROL VIOLATION STATE OF VIRGINIA, CITY OF ALEXANDRIA, to wit: This day personally appeared before me ___YOUR NAME___________ who, after first being duly sworn, deposed and said as follows: 1. That he/she resides at __YOUR ADDRESS_________________________ and may be reached at the following telephone numbers: _YOUR PHONE NUMBER (S)____. 2. As described below, he/she personally observed the following occurrence or condition: I personally observed a violation of ยง _5-7-42(2)_ of the City Code of the City of Alexandria, Virginia, 1981, as amended (City Code) on (DATE THE VIOLATION OCCURRED). The violation consisted of a brown male dog (the best description of the dog) defecating on the common ground in the 1200 block of Sesame St. being walked by Mr. Joe Smith who lives at 1234 Sesame St. and Joe Smith was viewed not picking up after this brown male dog after it defecated on the private property of the Cameron Knoll community.__________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________ 3. That, subject to paragraph 4, all of the foregoing information is submitted in confidence with respect to an active administrative investigation of a possible violation of the Animal Control Code of the City of Alexandria. 4.

That in the event administrative and/or court proceedings are initiated against any party responsible for the occurrence or condition reported above he/she will, upon reasonable notice, appear at such proceedings and testify on behalf of the City of Alexandria. ___________________________ SIGNATURE

SUBSCRIBED AND SWORN to before me, this

day of ____________, 2012. ___________________________ Notary Public

My Commission Expires: _________________________


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