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Mahaska Humane Society Spay/Neuter Assistance
Program Application
The Mahaska Humane Society Spay/ Neuter Assistance Program subsidizes the cost of neutering dogs and cats owned by residents of Mahaska County who cannot reasonably afford to pay for this procedure.
This application must be completed and signed by you (the applicant) and returned to the program coordinator. No funds will be disbursed unless and until you sign the application form.
The information you provide will be held in confidence by Mahaska Humane Society.
Submit this form then bring in proof of income (paystub, social security income, ect...) and proof of residency (utility bill with name and address, drivers license, ect...)
Name
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First
Last
Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Phone
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Pet to be spayed or neutered
Name, Species, Breed, Age, Sex
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Monthly family income (take home) from all sources
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Number of Persons in Household (relying on your support)
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Average monthly living expenses (housing, food, clothing, transportation, ect...)
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Current Employer
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Other Pets in the house
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Your veterinarian and Phone Number
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Check any that apply to you:
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Meet federal/state low-income guidelines
Retired on fixed income
Single person supporting dependents
Unemployed
Disabled
Explain why you cannot reasonably afford to spay or neuter your pet. Provide other relevant information.
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Where did you hear about this program
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Have you previously received support from the Mahaska Humane Society Spay/ Neuter program?
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Yes
No
Unsure
If yes, when?
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Read and sign the following agreement:
I am a resident of Mahaska County
I cannot reasonably afford to have my pet spayed or neutered
I have freely selected the veterinarian to whom i will take my pet to be spayed or neutered
I agree to pay for all pre-operative and post-operative treatment and for all required vaccinations
I have freely decided to have my pet neutered and declare the Mahaska Humane Society to be exempt from all responsibillity and liability for any pre-operative, operative and poet-operative complications, should they occur.
I have Sufficient assents to and do adequately care for and feed my pet
I have read (or been read) this application in its entirety
I understand, agree to, and will comply with all terms and conditions of the Mahaska Humane Society Spay/Neuter Program.
All information I have provided to the Mahaska Humane Society Spay/Neuter Program, including details about my income and expenses, is true and correct.
Signature
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Clear
