Assistance

HUMANE SOCIETY OF WASHINGTON COUNTY

GRANT PROGRAM

DOG AND CAT SPAY/NEUTER ASSISTANCE APPLICATION

Program Effective Date 9/1/2010

To apply for assistance to spay/neuter your dog or cat, please complete all sections of this application and mail with your proof of need to Humane Society of Washington County, 204 W. Joseph Street, Salem, IN 47167, fax to 812 472 3512 or scan and email to ddaugh@blueriver.net. If you are found eligible, you will be notified. Normal application processing time is 2 to 3 weeks. Values of the vouchers will be $50 for a female dog and $30 for a male dog; $25 for a female cat and $15 for a male cat. You may request assistance for up to 2 animals within a 12 month period. Please wait to be contacted before scheduling surgery.

PLEASE READ THE INSTRUCTIONS BELOW CAREFULLY. FAILURE TO COMPLETE THE APPLICATION IN ITS ENTIRETY WILL RESULT IN THE APPLICATION BEING DENIED.

Eligibility requirements:

1. You MUST be a resident of Washington County.

2. You MUST need financial assistance to spay or neuter your pet. That means meeting any one of the following qualifications:

EBT card (food stamps): copy of card with photo ID and food store receipt dated within the past 3 weeks

WIC card (with current date)

Supplemental Security Income (SSI), Social Security or Social Security Disability: Letter from Social Security Administration.

Section 8 Public Housing: letter from HUD

IRS FORM 1040 (not W-2 or pay stub) showing income levels at or below:

1 person household: $20,036

2 person household: $26,955

3 person household: $33,874

4 person household: $40,793

5 person household: $54,631

6 person household: $61,550

For each additional person add $3,740

A letter explaining special circumstances that will be reviewed at the next regularly schedule humane society board meeting. Meetings are held the third Tuesday of each month.

3. You MUST use one of the participating veterinarians -

McDonald Veterinary Clinic, Moore Animal Care Clinic or Salem Veterinary Service

Assistance money cannot be used if declawing, tail docking, ear cropping, or any other mutilating procedure is to be done at the time of the spaying or neutering. Money received from the Humane Society of Washington County cannot be used for services other than spaying or neutering.

I understand that by signing this form, I am agreeing to have my pet spayed or neutered.

I understand that HSWC does not maintain any responsibility toward my pet.

I understand that in the event I am found ineligible, I may appeal the decision at a regularly scheduled HSWC board meeting.

MONEY WILL ONLY BE AVAILABLE UNTIL GRANT FUNDS ARE EXHAUSTED

AND WILL BE AWARDED ON A FIRST COME, FIRST SERVED BASIS

Pet Owner’s Name________________________________________ Phone _____________

Address ___________________________________ City ___________ State ______ Zip ___________

Email address: __________________________________________________

Pet’s Name : _________________________ Sex M / F Age_____

Breed: _______________ Color: ______________ Weight: _______

Veterinarian who will perform surgery: ______________________________________

By signing this, I agree that I am a Washington County resident and the information provided regarding financial assistance is true and accurate.

Would you be willing to do volunteer work for this assistance? If so, when and in what capacity?

____________________________________________________________________________________

Signature of Applicant ____________________________________ Date_________________

We value your privacy. Your information will not be shared with anyone. It is for program qualification purposes only.