LOW INCOME ASSISTANCE APPLICATION NameFirstLast Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Phone EmailThe reason for Spay/Neuter Assistance (COMPLETE ALL OR MARK N/A if not applicable) Total Household Income Last Year, before Taxes, in USD Also. please put your Income PerMonthTwo WeekWeek $List allHousehold members other than yourself. Indicate Full Time or Part Time forthose employed or state student, unemployed, retired, disabled, etc. Name 1 Age 1 Occupation 1 Job Type 1Full-TimePart Time Name 2 Age 2 Occupation 2 Job Type 2Full-TimePart Time Name 3 Age 3 Occupation 3 Job Type 3Full-TimePart Time Use this space to put additional family members Do You Receive: (Check All that Apply) Food StampsTenncareWICSupplemental Security Income (SSI)Rental AssistanceAid to Dependant Families (AFCD/TAFDC)UnemploymentSocial SecurityOtherBy typing my full name here and dating this application, I affirm that the above information is true and correct Type Your Full Name Here DateUpon request, you must provide proof of income: Tax Return, Bank Statement showing Federal Government Deposits, Employee Check Stub Pet's Name: TypeDogCat Age SexMaleFemale Estimated Weight Color BreedSPAY/NEUTER SURGERY – Must be PREPAID (including vaccinations, other services) prior to scheduling. The Grant covers the cost of surgery up to 50lbs. We accept cash, checks and paypal (add a $3.50 service fee) NO REFUNDS. All patients will be given a pre-surgery exam the day of surgery. DOGS: (nail trim & a 24 hour pain injection included) SPAY-FEMALE-Ovariohysterectomy 5-50 lbs. $051-74 lbs. $2575-100 lbs. $65Pregnancy up to $50 extra (due on pick-up)Umbilical Hernia Repair $15 DOGS: (nail trim & a 24 hour pain injection included) NEUTER-MALE- Castration5-50 lbs. $051-74 lbs. $2075-100 lbs. $60Cryptorchid, $25+ depending on size (due on pickup) Post-Surgical Upon Discharge REQUIRED for dogsE-Collar $5E-Collar Over 75 lbs. $10Pain Meds $10Pain Meds Over 75 lbs. $15 CATS:( a 24 hour pain injection included) Neuter-Male (Castration) $0 Spay-Female (Ovariohysterectomy) $0Pregnancy up to $40 extra (due on pickup)Pain Meds $15E-Collar $5Inside CatOutside CatFeral Cat (Eartip given at no charge)Cryptorchid $25+ depending on size (due on pick-up) DOGS: Requested Vaccines and Services Rabies 1yr $10-required (or proof of current vaccine)Distemper/Parvo (DA2PP) $10Bordatella/Kennel Cough $10Heartworm Test $20 CATS: Requested Vaccines and Services Rabies 1yr $10-required (or proof of current vaccine)Distemper (FVRCP) $10Leukemia (FELV) $15 (Need proof of negative FeLV test) FeLV/FIV Test $25 Other Optional services during surgeryMicrochip $20Fecal $10De-wormer (Dog) starts at $10Profender (Cats) $15Flea/Tick $10 Financial Documentation/Proof of IncomePlease carefully read the following:Additional fees/charges may apply at time of pick-up due to higher weight, unexpected pregnancies, cryptorchid surgeries, umbilical hernias, or other services that may be needed for your animal at our veterinarian’s discretion. If any animal has live fleas, a capstar will be given to kill fleas immediately and to keep the surgery site sterile. An additional charge of $5 per capstar will be due at pick-up. You will be notified of any additional costs the day of your appointment. All cats MUST arrive in carriers, and dogs must be leashed. NO CHECKS are accepted in office day of surgery.IF PAYING ONLINE WITH PAYPAL OR CREDIT CARD, USE THE DONATE BUTTON. FEES MUST BE PAID BEFORE ANY PRODUCTS OR SERVICES LISTED ABOVE Single ChoiceMail CheckPayPal (Must add $3.50 fee to your payment)Credit/Debit ($3.50 fee for under $150, 4% for over $150)By typing my full name here I, the owner, acknowledge that I have read and understand this statement, and that I am responsible for all payments due at time of pick-up. I will pay any additional fees/charges that are due in office in addition to what I have sent with this application Form SignatureSubmitReset 846 Union St. Shelbyville, TN 37160 Call Us 931-684-5353 EMAIL US mtsnc@mtsnc.org
