The Humane Society of Calloway County

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THE HUMANE SOCIETY OF CALLOWAY COUNTY P. O. Box 764 Attn: Spay/Neuter Committee Murray, KY 42071

APPLICATION FOR SPAY/NEUTER ASSISTANCE

If you are approved for spay/neuter assistance, the Humane Society will pay 25% and the veterinarian will pay 25% of the cost to spay or neuter your cat or dog at participating Calloway County veterinary clinics.* Do not apply for this help unless you meet the guidelines below, or, if there are special circumstances, please describe them. Mail this FULLY COMPLETED FORM to the address above.

To receive help, your gross household income must be NO MORE THAN what is listed below: Number in household Monthly income Number in household Monthly income 1 $1057 4 $2097 2 $1390 5 $2450 3 $1744 6 $2803

Today's Date______

Applicant's Name______Phone______Please Print Clearly

Address______Street or P.O. Box City State Zip

Number of people in household______Total family income per month______

Employer for each person in household, if applicable: ______

Other sources of income: ______

Veterinarian or clinic you use______Clinic's phone______

Local reference: Name______Phone______

Address______

Your pet's name______Dog?______or Cat?______Female?______or Male?_____

If approved, your spay/neuter certificate will be mailed to you. You must present it when you pay the vet's bill. You will pay 50% of the bill to spay or neuter your pet, 25% will be paid by the veterinarian and 25% will be paid directly to the vet from the Humane Society's Fixed for Life Spay/Neuter Fund. You are responsible for making the appointment for the operation and for any additional expenses incurred.

*Participating veterinary clinics: Murray Animal Hospital; Veterinary Medical Center; Warner Animal Clinic; and Westside Veterinary Service. #______Form from ______7/06