Pa. Pets Low Income Spay Neuter 1.11.14

1 PA. (PREVENT EXCESS THROUGH STERILIZATION) 203 EAST FIFTH STREET, BLOOMSBURG, PA 17815 PA. pets LOW Income spay Neuter APPLICATION This Program is available to Columbia/Montour Residents. Instructions: 1. Fill out this form. 2. Enclose proof of Income for ALL HOUSEHOLD MEMBERS. (Copy of pay stubs, W2s, Tax Returns, or SSI statements, etc.) 3. Enclose co-payment (money order or cash only, checks will not be accepted) 4.

2 Mail this form with proof of Income along with your money order payable to PA. , or pay with money order or cash at the PA. Store, 203 E. Fifth St., Bloomsburg, PA 17815 between the hours of 9:00 AM and 4:30 PM on Wednesday, Thursday, Friday, & Saturday. DO NOT MAKE YOUR VET APPOINTMENT UNTIL PA pets CALLS YOU! Owner _____ Phone (home & cell) _____ Address_____ City/State/Zip _____ Pet s Name_____ Dog_____ Cat_____ Female_____ Male_____ Has animal had shots? _____ Pet s Age_____ Pet s Weight_____ Is pet pregnant? _____ Current Veterinarian?

3 _____ None _____ Veterinarian choices: No Preference_____ or one of the following: North Berwick Animal Hospital _____ Leighow Vet Hospital ____Animal Care Center_____Bloomsburg Vet_____ TO BE FILLED OUT BY PA. REPRESENTATIVE: Amt. Paid $_____ Grantee Representative Issuing Authorization_____ Date_____ Application to Vet. (Date) _____ Surgery to be done by (Vet.)_____. Your co-pay is based on total household GROSS Income per year: REMEMBER TO MAIL PROOF OF Income AND COPAYMENT WITH YOUR APPLICATION! _____ Income up to $10,000 - you pay $ 5 per animal _____ $10,000 - $20,000 - you pay $10 per animal _____ $20,000 - $30,000 - you pay $15 per animal PA pets will be responsible for the entire spay / Neuter fee; however, any additional charges provided by the veterinarian ( shots), will be the OWNER S responsibility.

4 Be advised that these charges can vary among veterinarians. A representative from PA will be in touch with you within one or two weeks after the application is received. Please note that this certificate is only good for 45 days. If the applicant has any questions, please call (570) 784-5520. Owner s Signature_____ Date_____ Revised 6/4/2016