Financial Assistance Form

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About You

Your Name(Required)

First Last

Your Address

Street Address Address Line 2 City State ZIP Code

How Can We Reach You?

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Your Email Address(Required)

Your Phone(Required)

Work Phone

Marital Status

Number of Children

Please enter a number less than or equal to 10.

Ages of Children

Total Income

Employers

Number of Male Dogs

Please enter a number from 0 to 20.

Number of Female Dogs

Please enter a number from 0 to 20.

Number of Male Cats

Please enter a number from 0 to 20.

Number of Female Cats

Please enter a number from 0 to 20.

Annual Total Family Income

Number of People in House

Please enter a number less than or equal to 12.

Your Comments/Questions(Required)

Eligibility for assistance for state program: In order to qualify for the State Spay-Neuter program, combined family income must be less than 100% of the Federal Poverty Level, or you must prove eligibility for Medicaid or Food Stamps. Please provide the following information:

(Annual total family income) (Number of people in household)

1) Documentation for proof of income. Examples to submit include the following: most recent tax
return, W-2’s, Social Security letter, check stubs indicating monthly income, unemployment paperwork. Bring your tax returns into our building. Do not email those!

2) Documentation for proof of eligibility for Medicaid and/or Food and Nutrition Services: a copy of the letter (not the card) that you receive from the government

Eligibility for HSDC program: If you do not qualify for the state program, we may be able to pay a portion of the spay-neuter cost. Please submit proof of income, as well as any special circumstances you have for seeking financial help, and we will process your request.

By signing this document, you are attesting that all information provided is true and accurate.