XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> SCFAW - Request for Services Application
About Us Spay/Neuter Services
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Request for Services Application
Statement of Income

If there is a problem with the online form please email us at scfaw@comcast.net
If you prefer to print out an application, fill it out by hand and mail it please click here to download the print version of this application.

* Name (first, last):

* Street:

* City/State:   * Zip:

* Email: (or "none")

Phone #(include area code):
* Home: Work: Cell:

If you participate in any public assistance programs please check which ones:
Food Stamps


Federal Supplemental Security Income (SSI)

Aid to Families with Dependent Children

Rental Assistance

Fuel Assistance

Social Security

Women, Infants, Children (WIC)

Unemployment Benefits

Other Programs (please describe below):

If you DO NOT participate in any public assistance programs, please enter your current total household take-home pay:

$ per week:


$ per two weeks:


$ per month:

Additional income per month


Child Support:


Number of household members, including yourself, who rely on the above stated income:

Please complete ONLY the section(s) below that pertain to the pet or pets that are in need of services:

Spay/Neuter for Pet Cats and vaccinations if needed

Preferred clinic location:
How many cats do you need spay/neuter for?

Number of male cats:

Number of female cats:

Cat's approximate age(s):
Does your cat have any health issues?
If yes, please explain below:

Scratch's Patch-Up Fund

This program is for seriously ill or injured cats and dogs. Please give a brief description of the animal's problem:

Spay/Neuter for Stray or Feral Cats and vaccinations if needed

Number of male cats:

Number of female cats:

Number of unknown cats:



Spay/Neuter for Dogs and vaccinations if needed

Number of dogs needing Spay/Neuter:

I understand that these services are for those who are financially limited. I certify that the information in this application is accurate.

* Date: (NOTE: This statement is valid for 60 days)
* Signature:

Proof of public assistance OR proof of income will be required.
Mail application and related documentation to: SCFAW, PO Box 58, Stow, MA 01775


SCFAW - PO Box 118, Bolton, Ma 01740 - 978-779-8287 - info@secondchancefund.org