Spay Neuter Certificate Template Form – Fill Out and Use This PDF

INTRODUCTION

HOW TO APPLY

The “Paws for the Cause” Low Income Voucher Program offers

Complete, sign, and date the Application. Mail the completed

$10 spay/neutering of cats and dogs for qualifying residents of

application, proof of eligibility and residency, along with a self-

Temple and Belton. Owners choose where to have the procedure

addressed stamped envelope to:

done from a list of participating veterinary clinics. The voucher

ASSOCIATION FOR PET ADOPTION CENTER (APAC)

program is funded by APAC, grant money and donations that go

P.O. Box 2351 • Temple, TX 76505

into a designated account to pay the veterinarians a reduced fee

to perform the surgeries. The goals are to increase the number of

If approved, you will receive a voucher good for up to two pets

pets spayed/neutered, reduce the number of unwanted cats/dogs

per family and a list of participating veterinarians that includes

born, and reduce the number of animals euthanized.

their address and phone number. For more information call

APAC at 254-298-5732.

WHY SPAY AND NEUTER?

There is a serious pet overpopulation crisis.

Over 3,100 dogs/cats are euthanized in the

Temple Animal Shelter each year. Six million

Full Name ________________________________________________________

dogs and cats are killed in the country every

year because there aren’t enough homes. The

Street Address _____________________________________________________

number of healthy dogs/cats euthanized each

City ____________________________

State/Zip _______________________

year can be greatly reduced if more pet own-

ers spay/neuter their animals. Other benefits

Home phone _____________________

Work phone_____________________

of spaying/neutering your pet(s) include:

Number of adults and/or children in household: _____________

• Improved health / Longer life

•

Reduced medical bills

Total household monthly gross income (before taxes) $______________

• No unwanted puppies and kittens

• Less aggressiveness, roaming, spraying

Name of Pet

Dog/Cat

Breed

Sex

Age

Color

and marking

ELIGIBILITY

__________________

_____

______________

____

_____

_______

To be eligible a person must be at least 18

__________________

_____

______________

____

_____

_______

years old, be a resident of Temple/Belton, and

be a recipient of or be eligible for one of the

Proof of eligibility and residency is required:

following state programs:

1. Attach a copy of your proof of eligibility.

•

Food Stamps

2. Attach a copy of any one of the following to prove residency at the address

• Temporary Assistance for Needy Families

•

Supplemental Security Income

listed above: Utility bill (electric, phone, water, etc.), driver’s license, or

• Social Security Disability (SSD)

government issued photo ID.

•

Medicaid

I hereby certify that the information I have provided is truthful and correct to the

In addition, you must:

best of my knowledge. I hereby agree to waive any and all claims for damages

• Have proof of your eligibility.

against APAC and participating veterinary clinic, its officers and employees in the

event of death or injury to the animal during the surgical sterilization process.

• The dog(s) and/or cat(s) must live in

Furthermore, APAC will not be held liable for any additional charges related to the

Temple/Belton.

voucher beyond the face value of the voucher. I understand that many veterinarians

• Agree to pay $10 co-payment (cash

only) to the veterinarian at the time

require specific vaccinations prior to sterilization, and I will be responsible for com-

of surgery.

pliance with theses requirements. I understand that if the participating veterinary

Each household may receive up to two

clinic determines that my pet is unmanageable, dangerous, vicious, wild or in any

way demonstrates the potential to injure animal care personnel, the participating

vouchers. Each voucher has a 90-day expira-

tion date. Please request only the number of

veterinary clinic reserves the right to refuse to spay and neuter your pet.

vouchers you will use within 90 days.

Owner’s Signature__________________________________

Date__________