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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Scratch


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

Medicaid

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:

OR

$ per two weeks:

OR

$ per month:


Additional income per month

Alimony:

Child Support:

Other:

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:
Athol
Gardner
Worcester
Leominster
Lancaster
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?
No
Yes
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:

Friendly

Unfriendly



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:


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


    Paws  
 

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