Bainbridge Decatur County Humane Society
Application For Spay or Neuter Assistance
If you prefer, Download the PDF Application For Spay or Neuter Assistance
Your Full Name
eMail Address
Day Phone
Night Phone
Cell Phone
Street Address
City, State, Zip
County
Income And Household Information: Please list all sources of income for the entire household. This includes wages, alimony, child support, social security, etc, whether it is for you, your spouse, children, or other people living in the same house. If you need additional space, use another sheet.

You must submit proof of income by providing copies of your current 1040 tax form OR proof of state/federal benefits (social security, unemployment, SSI, medical card, etc.), or any pension benefits. W-2 statements alone will not be accepted.
Monthly Source of Income Amount

Pet's Name
Pet's Age
Sex   Male   Female
Type   Cat   Dog
Has your cat ever been tested for Feline Leukemia?   No   Yes
Dog Breed
Dog Size   1 to 25 lbs   26 to 50 lbs   51 to 75 lbs   76 to 100 lbs
Is this pet current on shots?   No   Yes
Does this pet live mostly:   Inside   Outside
If this pet is female, how many litters has she
Is She Nursing Now   No   Yes
Age of Litter in Weeks
Does your pet have any conditions that we should be made aware of (diabetes, heartworm, etc.)?

Pet 2
Pet's Name
Pet's Age
Sex   Male   Female
Type   Cat   Dog
Has your cat ever been tested for Feline Leukemia?   No   Yes
Dog Breed
Dog Size   1 to 25 lbs   26 to 50 lbs   51 to 75 lbs   76 to 100 lbs
Is this pet current on shots?   No   Yes
Does this pet live mostly:   Inside   Outside
If this pet is female, how many litters has she
Is She Nursing Now   No   Yes
Age of Litter in Weeks
Does your pet have any conditions that we should be made aware of (diabetes, heartworm, etc.)?

Describe other pets you have?
Are these pets sterilized?
Please State Other Circumstances That Would Be Relevant To You Receiving Assistance With Spay/Neuter Of Your Pet:
Who is your current veterinarian or the
veterinarian you plan to use for this surgery
  Declaration And Release: I certify that the above information is true and complete. I hereby authorize the Bainbridge-Decatur County Humane society to contact my employer(s) and or any agent to verify income.