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Bylaw Community Safety - Incident Statement

This is not a complaint form. Please access the complaint form here.

Only complete this form if you have an open file and are instructed to do so by a Township of Langley Bylaw Enforcement Officer. Once your statement is received, the Officer assigned to your file will follow up.

Statement provider

First name

Middle initial

Last name

Date of birth

File number

Home address

Phone

Address of where the incident occurred

Statement

Describe the incident. Please include as much detail as possible.

Declaration of Truth and Accuracy

I hereby declare that the information provided in this statement is true, complete, and accurate to the best of my knowledge, belief, and recollection at the time of submission.

I understand that this statement is being provided in relation to an Animal Control or Community Safety matter and may be relied upon by the Township, its officers, and authorized agencies for the purposes of investigation, enforcement, administrative review, adjudication, or court proceedings.

I understand that knowingly providing information that is false, or misleading may have legal consequences.

I agree - Declaration of Truth and Accuracy

Yes

Use of Statement

I understand and agree that this statement may be used as evidence in court proceedings, administrative hearings, or adjudication processes, and may be disclosed to enforcement officers, legal counsel, adjudicators, courts, or other authorized parties as required by law.

I understand that I may be contacted for clarification, follow-up, or to provide testimony in relation to this matter.

I agree - Use of Statement

Yes

Electronic Signature and Consent

By selecting “I agree” and submitting this form, I acknowledge and agree that:

I am electronically signing this statement
My electronic submission has the same legal effect as a handwritten signature
I have read and understood the contents of this declaration in full
I am submitting this statement voluntarily and without coercion

I agree - Electronic Signature and Consent

Yes

Privacy Notice (FOIPPA)

Any personal information collected on this form will be managed in accordance with the Freedom of Information and Protection of Privacy Act. Direct enquiries, questions, or concerns regarding the collection, use, disclosure, or safeguarding of personal information associated with this form to:

Supervisor, Information, Privacy, and Records Management, Township of Langley,
20338 – 65 Avenue, Langley, BC V2Y 3J1
foi@tol.ca
604-532-7396

Confirmation

I confirm that the information provided is true and accurate to the best of my knowledge and that I have read, understood, and agree to the declaration above.

I agree - Confirmation

Yes