Weathersfield Residents - Spay Neuter Assistance Program for Domestic Pets

https://docs.google.com/document/d/18NQQ1YzAfESuiBaVLy6Aqljos7atKriWHddmSA4EmOs/edit

Town of Weathersfield

Spay Neuter Assistance Program

P.O. Box 550, Ascutney, VT 05030-0550

(802) 738-7413 ~ (802) 674-2626

Instructions for Applicants:

• Fill out Part 1 COMPLETELY. Failure to complete ALL sections of Part 1 may disqualify you from assistance.
• Call the Veterinarians Office and make an appointment.
• 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.)
• Send completed form and proof of residency (see below**) to the above address.    
• Mark the front bottom left corner of the envelope: Attn: Spay Neuter Assistance Program.
• 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: ________________________

Town of Weathersfield

Spay Neuter Assistance Program

• Available to all residents of the Town of Weathersfield, regardless of financial status.
• 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.)   
• Expenditures not to exceed $150.00 per household, per fiscal year.   
• Funded by dog license fees, individual donations and support from the Town.   
• Anyone who qualifies for VSNIP (Vermont Spay Neuter Incentive Program) will     be offered assistance to utilize that program.
• Funds will be available on a first come, first serve basis.
• 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.
• These funds must only be applied to the cost for spay/neuter of the domestic pet listed on the application.
• Any use/misuse of said funds will result in, but not be limited to, denial of any future use of this program.
• Any dog/wolf hybrid must be licensed with the Town in accordance to the Town of Weathersfield Animal Control Ordinance.  
  
  
  • Each domestic pet must have an individual application.