Piece Of My Heart Rescue Voucher Signup Form

Piece Of My Heart Rescue

Spay/Neuter Voucher Signup Form
Completion of this application is a must to receive a voucher.

Vouchers function as coupons that are $100 off a spay/neuter for the following breeds ONLY:
- Husky
- Hound (Coonhound, Beagle, etc.)
- Pit Bull
- German Shepherd
- Livestock Guardian Dogs (Great Pyrenees, Anatolian Shepherd, etc.)
If your household makes under $40,000/yr, you qualify for a $100 voucher. We reserve the right to possibly give out multiple vouchers to the same household on a case by case basis. You can either upload your W-2 or 1099, a copy of your past 3 paycheck stubs, or an unemployment benefits letter. If you are on a government program, upload proof of letter or card. If you are in the military or a veteran, upload that card as well.

THIS PROGRAM IS FOR RESIDENTS OF WASHINGTON, SCOTT, AND ORANGE COUNTIES *ONLY*

Proof of address is required via license or paycheck stub. (If you live in other counties that have an established voucher program, check with your local shelter for more info.)

This voucher can be combined with the Pet Friendly Services SNAP voucher. You can apply for a PFS SNAP voucher on either Monday morning at 9:00am (for all breeds, a $25 fee) or Tuesday at 8:30am (for Pit Bulls, a $10 fee) by going to this link: https://petfriendlyservices.org/spay-neuter-services/

Current POMH voucher participating Veterinarian clinics are:

Edwardsville Animal Clinic (Edwardsville, IN) - 812-923-8479 (also takes PFS vouchers)

Kentuckiana Veterinary Outreach (Sellersburg, IN): https://www.kvoutreach.org/

Smith Animal Clinic (New Salisbury, IN) - 812-347-2748 (also takes PFS vouchers)
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number (please list a working number with a functioning voicemail box)*

Area CodePhone Number
Can we text you at this number?*

YesNo
E-mail*
What is your total annual household income?*

Less than $10,000$10,001 - $25,00025,001 - $40,000$40,001-$60,000More than $60,000
Are you on any form of Government assistance/program? (Check all that apply)*

Energy Assistance ProgramFood Stamps (Hoosier Works)HIP (Healthy Indiana Plan)Major VA DisabilityMedicaid (not Medicare)Public School Free Lunch ProgramSection 8 HousingSocial Security Disability (SSD - Not Social Security Retirement Income)Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)Supplemental Security Income (SSI)Not on any government programOther
Please upload a copy of your ID, paycheck stubs, military card and/or government card/program documents:*

Browse Files

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Dog Info

List the quantity of dogs for which you need vouchers:*

	German Shepherd	Hound	Pit Bull	Husky	Livestock Guardian Dog
Male
Female

List each dog's name/breed:*
By signing this form, you acknowledge that you will be charged a no-show fee of $50-$100 if you don't show up for your appointment and the voucher will be voided. (Vets need a 48 hour cancellation notice to reschedule. This is a common courtesy to ensure vets participate in this voucher program.)

You must answer/confirm the veterinarian's surgery reminder call/text or your appointment will be cancelled and your voucher will be voided.

You are responsible for the additional costs of the surgery and required vaccines.
Signature*

Clear
Please verify that you are human*
Should be Empty:

Piece Of My Heart Rescue

Dog Info