HUMANE SOCIETY OF WASHINGTON COUNTY

Assistance Application

This is for Washington County Indiana residents only. Print out and mail to P.O. Box 51, Salem, IN 47167. If you are found eligible, a voucher will be mailed to you. Please wait to receive your voucher, before scheduling the surgery.

Eligibility requirements:

1. You MUST have a financial need for assistance.
2. You MUST be a resident of Washington County Indiana.
3. You MUST use one of our local Vets: Dr. Fisher, Dr. McDonald, or Dr. Moore.

·  I understand that by signing this form that I agree to have my pet spay/neuter. I understand that HSWC does not maintain any responsibility toward my pet. I understand in the event that I am not found eligible, I may appeal the decision at a regularly scheduled board meeting. Vouchers are issued on a first come, first serve basis.  Assistance will be limited to two pets per calendar year.

 

Money from the spay/neuter assistance comes from donations and/ or fund raising projects to the Human Society of Washington County. Please use this service only if you cannot afford the entire cost of the surgery.

Date _______________

Name_______________________________________________________ Driver’s Lic #________________________

Address________________________________________________________________________________________

City________________________________________________State__________________Zip___________________

Home Phone #_____________________Day #________________________Cell phone________________________

Are you employed?____________ if yes, where_____________________________________________________

Do you need this assistance? Yes__________ No______________

Type of animal: Dog_____ Cat______ Male_____ Female_______ Age___________Pet’s Name___________________

Breed____________________________________________ Color_________________________________________

Name of the Vet you will use________________________________________________________________________

Have you used this program before? ______________ When___________________________________________

And for what animal (s) ( give type, sex and how many) ___________________________________________________

______________________________________________________________________________________________

Do you still have the animals? ________________ If not, explain_____________________________________________

 Signature___________________________________________________ Date________________________