Town of Weathersfield Spay Neuter Assistance Program

Town of Weathersfield

Spay Neuter Assistance Program

1. Available to all residents of the Town of Weathersfield, regardless of financial status.
2. Reimbursement for up to $50.00 of the spaying/neutering of any individual domestic pet (as defined by the Town of Weathersfield Animal Control Ordinance) owned by a current resident. (Exceptions will be considered on a case by case basis.)
3. Expenditures not to exceed $150.00 per household, per fiscal year.
4. Funded by dog license fees, individual donations and support from the Town.
5. Anyone who qualifies for VSNIP (Vermont Spay Neuter Incentive Program) will be offered assistance to utilize that program.
6. Funds will be available on a first come, first serve basis.
7. Approval of applications will be limited by the amount of funds available. In the case that applications exceed funds, a waiting list will be created by the date the applications are received.
8. These funds must only be applied to the cost for spay/neuter of the domestic pet listed on the application.
9. Any use/misuse of said funds will result in, but not be limited to, denial of any future use of this program.
10. Any dog/wolf hybrid must be licensed with the Town in accordance to the Town of Weathersfield Animal Control Ordinance.
11. Each domestic pet must have an individual application.
    
    
    Forms available at the Weathersfield Town Office, on WeathersfieldDirectory.com , by emailing lynnesty@comcast.net
    
    
     
    
    Town of Weathersfield
    Spay Neuter Assistance Program
    P.O. Box 550, Ascutney, VT 05030-0550
    (802) 738-7413 ~ (802) 674-2626
    
    
    1. Instructions for Applicants:
    2. Fill out Part 1 COMPLETELY. Failure to complete ALL sections of Part 1 may disqualify you from assistance.
    3. Call the Veterinarians Office and make an appointment.
    4. On the day of the surgery, bring this paperwork and cash/check for the cost of surgery. Have the Veterinarians Office fill out Part 2: Veterinarian Information. (~~Please attach copy of bill.~~)
    5. Send completed form and proof of residency (see below**) to the above address.
    6. Mark the front bottom left corner of the envelope: Attn: Spay Neuter Assistance Program.
    7. You will receive your reimbursement in 2 to 4 weeks.

Part 1- Client Information (please write clearly)

Name of Applicant: _________________________________ Phone Number: __________________

Email: ____________________________ Physical Address: ________________________________

Mailing Address: _____________________ City/State/Zip: _________________________________

Circle One: Male Dog Female Dog Female Cat Male Cat Wolf-hybrid M / F Ferret M / F

Name of Animal: _________________ Breed: ______________________ Weight: _____________

Age of Animal: _______ Description of Animal: __________________________________________

Veterinarian: ______________________________________ Phone Number: ___________________

How many litters has this animal had? _________ Are all your other pets spayed/neutered?  Y   N

I hereby attest that I am a current resident of the Town of Weathersfield, Vermont, and the domestic pet I am applying for financial assistance to spay/neuter belongs to the Applicant. I attest that the above information is true and correct and that I am the true care-giver for this animal.

Signature of Animal Owner: ___________________________________ Date: _________________

~~~~~~~~~~ Applicant – Please Stop Here~~~~~~~~~~

Part 2 – Veterinarian Information (please write clearly)

Hospital/Clinic Name: ______________________________ Phone Number: ___________________

Mailing Address: ________________________ City/State/Zip: ______________________________

Date of Spay/Neuter: ___________________ Cost for Spay/Neuter ONLY: $___________________

Signature of Veterinarian Performing Surgery: ____________________________________________

~~~~~~~~~~Veterinarian – Please Stop Here ~~~~~~~~~~~

Part 3 – Authorization of SNAP Administrator

**Proof of Residency: Voter Checklist (___) Utility Bill (___) Land Owner (___) Other (___) _____

(Please attach copy of the utility bill being submitted as Proof of Residency)

Case #: :____________ Dog License #: _____________ Amount Reimbursed: $_________________ Authorization: ____________________________________ Date: ____________________________