If you qualify,
this program will ASSIST with the cost of Spay/Neuter surgery.
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NAME:________________________________ PHONE:
________________________DATE:_________________
ADDRESS: _____________________________ Town/City ____________________________Zip _______________
# of ADULTS in household:_______ # of CHILDREN in household:_____ Do you receive public assistance: _________
IF YES, Please submit Copy
of PA & Food Stamp Budget
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Place of Employment (applicant) _________________________________ Gross Income:______________________
Place of Employment of others in the
Household: ______________________ Gross Income: ____________________
Gross Income of Others in Household ____________ TOTAL
GROSS INCOME FOR HOUSEHOLD:_____________
SUBMIT COPIES OF
PAYROLL STUBS; INDICATE IF IT IS
WEEKLY OR BI-WEEKLY (circle one)
SELF EMPLOYED PERSONS SUBMIT COPY OF FRONT PAGE OF FEDERAL INCOME TAX
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DO YOU RECEIVE SOCIAL SECURITY? _______ Monthly Amount:_______________
Do you receive a Pension? ________ Monthly Amount of Pension: __________________
Other Household income: ___________________ Total Household income: _____________________
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MY SIGNATURE INDICATES ALL OF THE ABOVE INFORMATION IS CORRECT & TRUE!
_____________________________________________________________
Applicant Sign
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ANIMAL
INFORMATION
Dog or Cat (circle one) Male or Female (circle one) Has pet had Shots?_______ Had a litter______
Was this animal purchased from a Breeder or a Pet Shop? (circle one) Yes No
IF YOU ARE APPLYING FOR MORE THAN ONE ANIMAL, LIST THE OTHERS ON THE BACK OF THIS APPLICATION.
Be sure to list if they are male or female.
Have you ever surrendered an animal to a Humane
Society or SPCA? ________. Please explain on the back:_________________
_________________________________________________________________________________________________________
Additional
Comments Can be Made on Back of This Application
If you qualify for help, a list of Veterinarians who accept our vouchers will be attached to your voucher.
Questions or more information, please
call (315) 324- 5969
PLEASE NO BLANK SPACES... ANSWER ALL OR PUT N/A IF IT DOES NOT APPLY!
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Return Completed Application to:
SPAY/NEUTER/NOW (SNN
47 Duck Cove Road
HAMMOND, N.Y. 13646
SNN serves St. Lawrence, Jefferson, Franklin Counties of New York.
All information given on this application is strictly confidential!