SNAP-NC P.A.L.S. PROGRAM APPLICATION

(Prevent Another Litter Subsidy Program (Income Based)

This program provides subsidies for sterilization of dogs and cats and is available as funding allows.  The co-payment is $20.00 cash for cats and $35 cash for dogs, with the balance covered through grants and/or donations.  The co-payment is due in cash on the morning of surgery and will include routine surgery, pain medication, rabies and distemper vaccination. (We reserve the right to limit the number of pets sterilized in any one family. We further reserve the right to refuse additional veterinary services not detailed above.)

In order to qualify, you MUST show proof of financial need.  Please attach a copy of proof of eligibility.  This can be any one of the following:

     1.  Medicaid card (for adult, not child)                                        5. IRS Form 1040 (NOT W-2 or pay stub)

     2.  WIC card (with current date)                                                            showing income levels less than

     3.  Social Security Income -                                                                           1 person household - $17,960

         (for adult, not for child)                                                              2 person household - $24,240

NOTE: Social Security Income is NOT                             3 person household - $27,468

a qualification unless social security                              4 person household - $ 33,120

is your ONLY income (provide copy                                5+ person household $ 34,464

of last year’s tax return or last three bank

statements showing deposit of SSI check.)    6. Letter explaining special circumstances

     4. EBT (food stamp) card with photo ID & food store                             and need for assistance.

         receipt dated within previous 3 weeks

You must have subsidy approval BEFORE scheduling your appointment.   Print out this form, fill it out, and mail it to SNAP-NC, P. O. Box 278, New Hill, NC  27562 with all supporting documents.  We will call you when we have processed your application and we will schedule your appointment at that time.  Please allow 10 business days.

Your first name _____________________      Last name___________________________

Address _____________________________City___________________ Zip__________

Phone: _________Alt Phone: __________      Total # pets in home_____ # NOT spayed___

Pet name _______________________  Dog (  ) Dog’s weight___   M__/F__        Cat (   ) M__F__

Pet name _______________________  Dog (  )  Dog’s weight___  M__/F__        Cat (   ) M__F__

Pet name _______________________  Dog (  )  Dog’s weight___  M__/F__        Cat (   ) M__F__

Pet name _______________________  Dog (  )  Dog’s weight___  M__/F__        Cat (   ) M__F__

I certify that the above named animal(s) are owned by me personally.  I understand that the co-payment fee is due in cash on the morning that my pet is dropped off for surgery.

Signature ___________________________   Date _______________________________

Note:  Please be sure to list all dogs and cats currently owned by you, as this could effect future applications for assistance.