Spay Neuter Assistance Application and Agreement

Spay Neuter Assistance Application and Agreement

Open to Jackson County, Alabama residents only
OWNER INFORMATION
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
FINANCIAL ELIGIBILITY
WelfareSocial SecurityDisabilityMedicaidFood AssistanceUnemployedYearly household income less than $40,000 per year
PET DESCRIPTION
Pet's Name
Breed
Color
CatDog
MaleFemale
Age (months/years)
Weight
In heatPregnantNursingHealthySickWild/Feral
YesNoOther
YesNo
List of approved veterinarians:
Phillip's Small Animal Clinic - Scottsboro

Mountain Top Animal Clinic - Pisgah

Mud Creek Vet Services - Hollywood

*Vouchers for male cats must be used at Philips Small Animal Clinic or Mountain Top Animal Clinic.
Certification
I give my word, under penalty of perjury, that the information in this application is correct and complete to the best of my knowledge. Please check the box next to each statement to agree.
I am responsible for a co-pay at the time of surgery; $30 for cats and $40 for dogsI understand that I am responsible for any additional costs that may be associated or arise from the spay/neuter surgery that may arise before, during or after surgery.I understand that the voucher issued to me is only to be used for the pet listed on the voucher.I acknowledge that I have read, understand and agree to the program requirements.
Please upload proof of income or benefits. Proof must be dated and uploaded with this application. Tax forms, government assistance documents or pay stubs may be used. Be sure to mark through any sensitive informatin such as social security numbers. If you are unsure what proof is adequate, please contact us.

An approval or denial letter will be sent to the email address provided so please make sure to check your email within three to five business days for further instructions. Vouchers are not issued without an appointment date. You are responsible for entire bill if you do not provide the veterinarians office with a voucher at time of appointment.
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Spay Neuter Assistance Application and Agreement

OWNER INFORMATION

FINANCIAL ELIGIBILITY

PET DESCRIPTION

List of approved veterinarians:

Certification