<p> #______</p><p>THE HUMANE SOCIETY OF CALLOWAY COUNTY P. O. Box 764 Attn: Spay/Neuter Committee Murray, KY 42071</p><p>APPLICATION FOR SPAY/NEUTER ASSISTANCE</p><p>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.</p><p>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</p><p>Today's Date______</p><p>Applicant's Name______Phone______Please Print Clearly</p><p>Address______Street or P.O. Box City State Zip</p><p>Number of people in household______Total family income per month______</p><p>Employer for each person in household, if applicable: ______</p><p>Other sources of income: ______</p><p>Veterinarian or clinic you use______Clinic's phone______</p><p>Local reference: Name______Phone______</p><p>Address______</p><p>Your pet's name______Dog?______or Cat?______Female?______or Male?_____</p><p>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.</p><p>*Participating veterinary clinics: Murray Animal Hospital; Veterinary Medical Center; Warner Animal Clinic; and Westside Veterinary Service. #______Form from ______7/06</p>