Low Income Assistance Application

Name*

First

Last

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Phone

Email*

The 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 Per

Month

Two Week

Week

$

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 1

Full-Time

Part Time

Name 2

Age 2

Occupation 2

Job Type 2

Full-Time

Part Time

Name 3

Age 3

Occupation 3

Job Type 3

Full-Time

Part Time

Use this space to put additional family members

By typing my full name here and dating this application, I affirm that the above information is true and correct

Type Your Full Name Here*

Date*

Upon request, you must provide proof of income: Tax Return, Bank Statement showing Federal Government Deposits, Employee Check Stub

Pet's Name:

Type*

Dog

Cat

Age

Sex*

Male

Female

Estimated Weight*

Color*

Breed

SPAY/NEUTER SURGERY – Must be PREPAID (including vaccinations, other services) prior to scheduling. NO REFUNDS.

The Grant covers the cost of surgery up to 50lbs. All pets must either receive a rabies vaccination at a cost of $10 or show proof of a current vaccination certificate. A cone and pain medication for dog post-surgical care is required at an additional cost (see box). 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

DOGS: (nail trim & a 24 hour pain injection included)
NEUTER-MALE- Castration

5-50 lbs. $0

51-74 lbs. $20

75-100 lbs. $60

Cryptorchid, $25+ depending on size (due on pickup)

Post-Surgical Upon Discharge REQUIRED for dogs

E-Collar $5

E-Collar Over 75 lbs. $10

Pain Meds $10

Pain Meds Over 75 lbs. $15

CATS:( a 24 hour pain injection included)

DOGS: Requested Vaccines and Services

Rabies 1yr $10-required (or proof of current vaccine)

Distemper/Parvo (DA2PP) $10

Bordatella/Kennel Cough $10

Heartworm Test $20

CATS: Requested Vaccines and Services

Rabies 1yr $10-required (or proof of current vaccine)

Distemper (FVRCP) $10

Leukemia (FELV) $15 (Need proof of negative FeLV test)

FeLV/FIV Test $25

Financial Documentation/Proof of Income

Please 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.

After we receive your application and proof of income we will contact you. You will be required to pay what the grant does not cover before an appointment is made. Appointments are not made until all payments are received.

Prepayment Options are:*

Money Order (prior to scheduling)

Cash (prior to scheduling)

Check (prior to scheduling)

PayPal (Must add $3.50 fee to your payment)

Credit/Debit ($3.50 fee for under $150, 4% for over $150)

NOTE: If paying with PayPal, please use the "Donate" button at the top of the page.

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 Signature*

NOTE: If paying with PayPal, please use the "Donate" button at the top of the page.

846 Union St. Shelbyville, TN 37160

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