City of Culver City Culver City Dog Licensing c/o PetData

1 city of Culver CityDog License Fee Exemption ApplicationPlease Print Clearly and Fill in All InformationQuestions? Call toll-free 1-888-615-4350 or Visit See Second Page for InstructionsOffice Use Only: Proof of ResidencyProof of SSI:Proof of Income:Proof of Age: c Baptism Certificate c Birth Certificate c Driver's License c Medicare CardDate:Approved By:Pet(s) Information (Enclose Current Rabies Certificate, Microchip Number and Proof of Spay/Neuter for each pet)Owner Last NameOwner First NameResidential Address (required)Apt/LotCityStateZipHome PhoneWork PhoneEmail Address (optional)Mailing AddressApplicant currently receiving SSI benefits for disability.

2 Q Yes q NoApplicant's Birth Date (mm/dd/yyyy):Applicant's Adjusted Gross Income during last Calendar Year:Household's Adjusted Gross Income during last Calendar Year:I certify (or declare) under penalty of perjury that all information submitted with this application is true to the best of my knowledge and 's SignatureOwner InformationEligibility (Enclose Proof) Voluntary Cat Voluntary Cat Dog Dog Sex Spay/Neuter Unaltered Spay/Neuter Unaltered Name: q M q F q $ q $ q $ q $ : q M q F q $ q $ q $ q $ : q M q F q $ q $ q $ q $ Enclosed:SignatureCulver city Dog Licensingc/o PetDataPO Box 141929 Irving, TX 75014-19291-888-615-4350 city of Culver CityDog License Fee Exemption InstructionsQuestions?

3 Call toll-free 1-888-615-4350 You may be exempt from paying the dog license fee if:1. You are a resident of Culver city ;2. You are 60 years of age or older;3. Your Total Adjusted Gross Income, as used for purposes of the California Personal Income Tax Law, was no more than $18,200 for the last calendar year;AND The combined Adjusted Gross Income of all members of the household in which you reside was no more than $21,500;OR4. You are a resident of Culver city who meets the criterion of Disability, as established by the Social Security Administration's Supplemental Security Income (SSI) Program for the Aged, Blind, and Disabled (Title SVI of the Social Security Act as amended), without regard to your Is Eligible?

4 How Do You Apply? Culver city Dog Licensingc/o PetDataPO Box 141929 Irving, TX 75014-19291-888-615-4350If you meet the requirements for the low-income senior citizen exemption, send: m Complete the first page of the form, and enclose. Be sure to sign the form! m Enclose utility bill with name and address. m Enclose proof of age (60+). m Enclose a copy of your California Income Tax Return (if you filed one).If you meet the requirements for the low-income SSI exemption, send: m Complete the first page of the form, and enclose. Be sure to sign the form! m Enclose utility bill with name and address.

5 M Enclose a Social Security letter stating that you are receiving SSI all applications, please include the following pet information: m Enclose current rabies vaccination certificates for each pet. m Enclose proof of spay/neuter for each pet, if applicable. m Include each pet's microchip number (all dogs must be microchipped). m Enclose check made out to city of Culver city if Licensing more than one all documents to: Culver city Dog Licensing c/o PetData PO Box 141929 Irving, TX 75014-1929 All statements, Income Tax Returns, and any other supporting papers will be promptly returned to you.

6 Rabies vaccination certificates and spay/neuter certificates will not be returned.