(Examples of financial assistance include: Social Security, Energy or Food Assistance,
Medicaid, Unemployment Benefits, etc.)
***If you answered yes to the above question, please attach a copy of your benefit letter or check stub to this application. ***
If you are NOT currently receiving any type of government assistance, please
answer the following:
What is the Total Gross Income (total annual income earned before taxes) of all those living in the household?
***If you are employed, please upload a copy of 2 months of your most recent
paycheck stubs to the application.***
Please note that determination of application approval will be based on benefits received or income earned. Please make sure to provide 2 months of paycheck stubs, W2 tax forms, Unemployment Benefit check stub, Social Security benefit check stub, or other income verification documentation to the application. The application process will be delayed if the documentation is not received at the time of the application.
By completing and signing this document, I am requesting that services be provided to my pet through LHAWA’s Spay Neuter Assistance Program. I understand that LHAWA provides funds to assist pet owners with the cost of spaying, neutering, vaccinations, or microchipping services that will be completed at a veterinarian's office and there is a portion of the cost that I must pay at the time of my scheduled appointment. A veterinarian is providing all veterinary services and LHAWA holds no liability in medical outcomes or additional services and/or costs you receive. I also understand that if I need to reschedule my original appointment that this must be done directly through your veterinarian 24 hours before the date of the procedure. In addition, I understand that if I NO CALL/NO SHOW my first appointment, I will be forfeiting SNAP assistance for 6 months and will be able to reapply again for services after 6 months has passed. If I NO CALL/NO SHOW the second application/appointment, I understand that I will be forfeiting SNAP assistance indefinitely.
Thank you! We will review your information, and we'll be in touch!