NEUTER PROGRAM APPLICATION FORM

Karen\SpayNeuterForm.Revised111110.frm Rabies Price Update 02/23/10 HUD Update 02/12/13 Address Update 02/13 WASHINGTON COUNTY SPAY/NEUTER PROGRAM AP...
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Karen\SpayNeuterForm.Revised111110.frm Rabies Price Update 02/23/10 HUD Update 02/12/13 Address Update 02/13

WASHINGTON COUNTY SPAY/NEUTER PROGRAM APPLICATION FORM Name of Pet Owner: Last

First

Physical Address:

City/Zip:

Mailing Address:

City/Zip:

Daytime Phone: Tell us about your animal: Dog or Cat: Pet’s Name: Breed: Any health problems? If so, explain: If female, is she pregnant or in heat?

Initial

Evening Phone: Male or Female:

Age:

Weight: Color:

This program is designed to help the pets of owners of restricted incomes to have access to spay/neuter surgery. Therefore, it is necessary that you state the combined gross incomes for all resident family members for the last calendar year. Number of Family Members:

Family Gross Annual Income:

Proof of income is required and must be included with this application form. Acceptable items to document proof of income are: last years W-2 statement; income tax statement; social security statement; disability reimbursement statement; or pay check stub. There is a $10.00 non-refundable fee per application. Checks should be made out to the Washington County Spay/Neuter Program. Many veterinarians have contracted with Washington County to be a part of this cooperative program to make spay/neuter surgeries available for the pets of Washington County residents of restricted income. A list of these veterinarians is attached. The approval voucher issued must list the veterinarian that you will be using for the spay/neuter surgery. The selected veterinarian for this application is: NOTE: A current certificate of vaccination for rabies signed by a licensed veterinarian is required by Arkansas Law. If you cannot present a certificate, your animal will be vaccinated and a certificate issued for a fee of $10.00, payable upon presentation of your animal for surgery. An additional fee will also be charged for boarding animals left overnight. I hereby certify that all the information reported above is true, accurate and complete. Further I certify that I am a resident of Washington County but do not live within the city limits of either Fayetteville or Springdale. Signature:

Date:

Send this completed and signed application, proof of income, and a self-addressed stamped envelope, to the Washington County Animal Shelter, 801 W. Clydesdale Drive, Fayetteville, AR 72701. An approval voucher or the denied application will then be mailed to the pet owner. Approved applications will only be valid for 45 days from the date of the voucher. Applications received during the Months of November & December may not be reviewed for approval until January. Pet owners must realize that this program has limited funding and will close when these funds are exhausted, whether or not there are outstanding, approved applications. Pet owners are urged to act quickly on approved applications.

Karen\SpayNeuterForm.Revised111110.frm Rabies Price Update 02/23/10 HUD Update 02/12/13 Address Update 02/13

THE WASHINGTON COUNTY – CITY OF FAYETTEVILLE COOPERATIVE SPAY/NEUTER PROGRAM Washington County and the City of Fayetteville’s Animal Shelter have entered into a cooperative program to make spay/neuter surgeries available for pets of county residents of restricted incomes. Eligibility to this program is limited to county residents who do not reside within the city limits of an incorporated city whose population is in excess of 10,000 and whose annual family incomes do not exceed the current Low Income Limits for Washington County as established by the U.S. Department of Housing and Urban Development (HUD). Proof of income is required and must be included with this application form. Acceptable items to document proof of income are: last years W-2 statement; income tax statement; social security statement; disability reimbursement statement; or pay check stub. NO PERSON, ENTITY OR ORGANIZATION THAT UTILIZES THE SERVICES OF THIS PROGRAM MAY SELL, ADOPT, OR RELEASE AN ANIMAL TO PERSONS WHO RESIDE OUTSIDE OF WASHINGTON COUNTY. ANY VIOLATION OF THIS IS PUNISHABLE AND ENFORCEABLE AS SET OUT IN WASHINGTON COUNTY CODE 2.7-25, AS AMENDED. (Ordinance No. 2009-69)

INSTRUCTIONS 1. Qualifying pet owners who live in Washington County, but not within the city limits of an incorporated city whose population is in excess of 10,000 and whose family incomes do not exceed the HUD income limits may obtain applications forms from the Washington County Animal Shelter, the Fayetteville Animal Shelter, libraries, participating veterinarians, as well as Washington County’s web site: www.co.washington.ar.us. 2. Complete one (1) application for each animal you wish to have spayed or neutered. No person, entity or organization may receive more than seven (7) vouchers per year; furthermore, the total number of combined persons residing at the same physical address cannot receive more than seven (7) vouchers per year; except as allowed otherwise on appeal to the Washington County Animal Concerns Advisory Board. 3. Applicants are required to pay a $10.00 non-refundable fee per application. Checks are to be made out to the Washington County Spay/Neuter Program. 4. Sign and mail or deliver the application along with proof of income and application fee to the Washington County Spay/Neuter Program, c/o County Animal Shelter, 801 W. Clydesdale Drive, Fayetteville, AR 72701 along with a self-addressed, stamped envelope. 5. Applications will be reviewed and recorded. An approval voucher or the denied application will then be mailed to the pet owner. 6. The pet owner may then make arrangements with the veterinarian designated on the approval voucher. 7. At least 5 days in advance of the appointment date, the pet owner must deliver or mail the voucher to the veterinarian. 8. The pet owner may deliver the animal for surgery and pick up the animal according to the arrangements made with the service provider. 9. An additional fee of $10.00 will be paid by the pet owner to the service provider at the time of delivery if the animal does not have a certificate of rabies vaccination issued by a licensed veterinarian and dated within the past year. Arkansas law requires such vaccination. 10. Additional fees as arranged with the service provider will be charged for animals boarded overnight either at the request of the pet owner or by instructions from the veterinarian. Any additional charges by the veterinarian are the sole responsibility of the pet owner. THIS PROGRAM HAS LIMITED FUNDING AND WILL CLOSE WHEN THESE FUNDS HAVE BEEN EXPENDED.

Karen\SpayNeuterForm.Revised111110.frm Rabies Price Update 02/23/10 HUD Update 02/12/13 Address Update 02/13

HUD FY 2013 WASHINGTON COUNTY, ARKANSAS LOW INCOME LIMITS

1 Person

$31,750

2 Person

$36,300

3 Person

$40,850

4 Person

$45,350

5 Person

$49,000

6 Person

$52,650

7 Person

$56,250

8 Person

$59,900

Source: http://www.huduser.org

Karen\SpayNeuterForm.Revised111110.frm Rabies Price Update 02/23/10 HUD Update 02/12/13 Address Update 02/13

WASHINGTON COUNTY SPAY/NEUTER PROGRAM PARTICIPATING VETERINARIANS Revised 06/12/12

FAYETTEVILLE All Cats Clinic Dr. M. P. Mohler 3100 N. College Fayetteville, AR 72703 (479) 571-1228

FARMINGTON Country Veterinary Services Dr. Tim E. O’Neill 12377 Jimmy DeVault Rd. Farmington, AR 72730 (479) 267-2685

Animal Medical Clinic Dr. M. P. Mohler 3045 Market Avenue Fayetteville, AR 72703 (479) 521-5220

Farmington Veterinary Clinic Dr. Alan Thompson 30 W. Main Street Farmington, AR 72730 (479) 267-3276

Cornerstone Animal Hospital Dr. Marty Turner 2295 E. Zion Road Fayetteville, AR 72703 (479) 443-0738

LINCOLN Lincoln Vet Clinic Dr. Diane Balich 2157 E. Pridemore Lincoln, AR 72744 (479) 824-3299

Fayetteville Animal Shelter 1640 Armstrong Road Fayetteville, AR 72701 (479) 444-3456 Gulley Park Pets Clinic Dr. Romy Core 2406 Old Wire Road Fayetteville, AR 72703 (479) 966-4929 Stanton Animal Hospital Dr. Donald Stanton 1817 Green Acres Road Fayetteville, AR 72703 (479) 443-4544 Wedington Animal Hospital Dr. Jack Herring 4363 Wedington Fayetteville, AR 72704 (479) 444-6600 West Oaks Animal Hospital Dr. Marty Nall 2820 Dorothy Jeanne Fayetteville, AR 72704 (479) 442-4446 Family Pets Vet Care Dr. Viki Cyphers 125 E. Township St., Suite 1 Fayetteville, AR 72703 (479) 521-7387

PRAIRIE GROVE Vinewood Animal Hospital Dr. Jeremiah Atha 11475 Suncrest Prairie Grove, AR 72753 (479) 846-4151 WEST FORK Noah’s Ark Veterinary Services Dr. Linda Ford 53 S. Centennial Ave. West Fork, AR 72774 (479) 839-2328

SPRINGDALE Crossover Veterinary Clinic Dr. Lauryl Hynes Dr. Beth Stropes 3980 S. Old Missouri Road Springdale, AR 72764 (479) 750-7474 Springdale Animal Hospital Dr. Elizabeth Carender 2903 W. Huntsville Springdale, AR 72762 (479) 751-2327 Lyon Vet Hospital Dr. Brad Lyon 5782 W. Sunset Avenue Springdale, AR 72762 (479) 361-4650 NWA Spay & Neuter Clinic Dr. Susan Connelly 1909 W. Huntsville Rd Springdale, AR 72762 (479) 756-1100 OKLAHOMA Patterson Animal Hospital Dr. Yalonda Burton Route 6 Stillwell, OK 74960 (918) 696-5867

Karen\SpayNeuterForm.Revised111110.frm Rabies Price Update 02/23/10 HUD Update 02/12/13 Address Update 02/13

BEFORE SUBMITTING APPLICATION HAVE YOU… □

Enclosed proof of income?



Enclosed application fee ($10 per animal)?



Selected a participating veterinarian? It is suggested that you call vet to confirm availability and any associated costs that they may charge prior to selection.



Signed & dated the application?



Enclosed a self-addressed stamped envelope?