Voucher Application — Spay Neuter Jackson County Alabama

Your Name prefix, Mr or Mrs?

Spay Neuter Assistance Application and Agreement

Open to Jackson County, Alabama residents only

OWNER INFORMATION

First name

Last name

Today's Date

Address

City

State

Zip Code

Phone number

Alternate Phone

Email Address

FINANCIAL ELIGIBILITY

PET DESCRIPTION

Pet's Name

Breed

Color

Species

Cat

Dog

Sex

Male

Female

Age (months, years)

Weight

Previous Litters:

Yes

Unsure

Do you have proof of a current rabies vaccination?

Yes

LIST OF APPROVED VETERINARIANS

Phillips Small Animal Clinic - Scottsboro

Mountain Top Animal Clinic - Pisgah

Mud Creek Vet Services - Hollywood

Due to limited funding and varying veterinary costs, we reserve the right to designate the veterinary provider

I agree

Due to cost limitations, vouchers cannot be used for cat services at Mud Creek Animal Services.

I agree

CERTIFICATION

I give my word, under penalty of perjury, that the information in this application is correct and complete to the best of my knowledge. Please check the box next to each statement to agree.

I am responsible for a co-pay at the time of surgery; $30 for cats and $40 for dogs

I understand that I am responsible for any additional costs that may be associated or arise from the spay/neuter surgery that may arise before, during or after surgery.

I understand that the voucher issued to me is only to be used for the pet listed on the voucher.

I understand that there is a limit of 3 vouchers per year per household

I acknowledge that I have read, understand and agree to the program requirements.

I understand I must upload proof of income or government assistance (below)

Please upload proof of income or benefits. Proof must be dated and uploaded with this application. Tax forms, government assistance documents or pay stubs may be used. Be sure to mark through any sensitive informatin such as social security numbers. If you are unsure what proof is adequate, please contact us.

An approval or denial letter will be sent to the email address provided so please make sure to check your email within three to five business days for further instructions. Vouchers are not issued without an appointment date. You are responsible for entire bill if you do not provide the veterinarians office with a voucher at time of appointment.