1
INCOME BASED SPAY/NEUTER APPLICATION
Name
______________________
_______________________
first
middle
Address _________________________________
last
__________ _
Street address/po box
Phone______________________
____________________
apt#
city, zip
______________________________
Primary
Secondary
Email address _____________________________
ONLY TWO DOGS AND CATS PER HOUSEHOLD MAY BE ELIGIBLE PER YEAR. APPOINTMENTS MAY BE
MADE A DIFFERENT TIMES FOR EACH ANIMAL AT THE VETERINARIANS CONVENIENCE.
Which type of animal do you wish to have spayed/neutered? Dog __☐____ Cat____ ☐ ____
Is the animal? Male___☐_____
Female___☐______
Age of animal_____________
INCOME INFORMATION
What was your gross income for 2011 (CHECK BELOW) will not make a difference in the cost.
_____☐______ BELOW $25,000
_ ___ ☐ _ ____ $25,000- $55,000
Please attach a copy of your most recent income tax filing report to this application. (If no tax report is
available, please attach copies of 3 of your most recent check stubs.)
How many people live in your household? _______________
2
____☐_______ I understand that if I am chosen to receive low cost assistance that I must pay in full to
participating veterinarian which will be in the range of $50-$65. This is based on household income,
Animal Clinic and type of animal ($50- $65).
____ ☐ _______ I understand that if my animal has had a rabies vaccination from an accredited source
(veterinarian only and must provide documentation); I will pay $10.00 less and I will pay for this services
before surgery can be conducted.
____☐_______ I understand that Kentucky River Regional Animal Shelter, Kentucky Department of
Agriculture or participating clinic are not responsible for any additional costs that may be associated
with the surgery on my animal. I will be responsible for additional costs but will be consulted by the
veterinarian before additional services are performed on my animal.
____☐_______ I understand that if my animal perishes during surgery that I will not be entitled to a
refund of my pay.
____☐_______ I understand that once my appointment is scheduled, if I fail to take my animal to the
participating veterinarian on the day and time of the appointment, my voucher will be cancelled and I
will not be eligible to receive spay/neuter assistance again in 2012 or a refund.
____☐_______ I have been presented with a list of recommended vaccines for dogs/cats and
recommended tests (ex. Feline leukemia and fecal test). I understand that these vaccines/ tests are at an
additional cost to me.
In 50 words or less, please explain why you need assistance for this income based program.
I certify that the statements given in this application are correct and that the information provided on
my tax return or check stubs are correct. I understand that failure to comply with stated guidelines or
providing inaccurate information may be a violation of the law and if I am selected to receive financial
assistance I will comply withal rules as outlined in this agreement.
__________________________________
Signature
_______________________________
Date
3
Which day of the week works best for you?
participating vets below.
Please see availability of the
Participating Vets
Dr. Holbrook ~ Jackson KY his cost is $50.00 for dog or cat this includes rabies. Available Tuesday and
Wednesday only, drop off one day pick up next.
Appalachian Animal Hospital ~ Hazard, KY their cost is $50.00 for cat and $65.00 for dog, $10.00 more
for dogs that are pregnant or in heat. Available Monday-Friday
All applications or questions must be submitted to the Kentucky River Regional Animal Shelter located
in Perry County or email to tnt@1234@windstream.net or phone K.R.A.D.D. at (606)436-3158.