Duncan's Legacy: Spay,Neuter and Care Application

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Spouse/Domestic Partner

If not applicable enter N/A

What county do you live in?

Place of employment

Occupation

How many people (including children) live in your home?

8. Do you currently receive any of the following forms of government assistance? (Check all that apply.)

Supplemental Nutrition Assistance Program (SNAP)

Medicaid

Supplemental Security Income (SSI)

Disability Benefits

Unemployment Benefits

Section 8 Housing Assistance

Temporary Assistance for Needy Families (TANF)

Women, Infants, and Children (WIC) Program

Other (please specify)

If you selected other please specify here:

Please upload a picture of your proof of assistance below. If you are receiving EBT or WIC, you must provide an up-to-date eligibility letter. Financial assistance must be current at the time of your appointment. We cannot accept a picture of your EBT or WIC card alone—we need to see the eligibility dates. For Medicaid, make sure your card shows a current date (within one year of the issue or effective date).

Upload File

Do you currently face financial hardship (e.g., unexpected expenses, job loss, etc.)? If yes, please explain briefly:

Dog's Name: (if there is more than one dog, you are required to fill out a separate form for each dog)

What breed or best guess:

Age of Dog:

Sex of Dog:

Is your dog spayed or neutered?

Yes

No

Date of last litter of puppies if applicable (all dogs must be at least 14 weeks postpartum for surgery)

Month

Day

Year

How long have you ad the dog?

Less than 3 months

3-6 months

6-12 months

Over a year

Where did you get your dog?

Shelter/Rescue

Found as a stray

Breeder

Friend/Family

Where does your dog spend most of their time?

Indoor

Outdoor

Is your dog up to date on vaccinations?

Yes

No

Does your dog have any medical conditions (e.g., heartworm, skin issues) or behavioral concerns (e.g., aggression, fear)?

Yes

No

If you selected "yes" please explain:

Why are you requesting assistance for spay/neuter services?

Have you previously applied for or received spay/neuter assistance? If yes, when and where?

How much can you contribute toward the spay or neuter surgery?

Do you have reliable transportation to bring your dog to and from the appointment?

Yes

No

Other

I agree to bring my dog to the designated clinic at the scheduled time and follow all post-operative care instructions.

Yes

No

Does your pet need a rabies vaccine for an additional $15, or will you provide proof of current rabies vaccination? Please note that all patients must either provide a valid rabies certificate or you will be charged for a rabies vaccine.

Yes my dog will need a rabies vaccine and I will be charged

No, I will provide a current rabies certificate

Please check if you would like additional services, keep in mind these services will be at YOUR expense:

Da2P Vaccine ($17.00)

Microchip ($25.00)

By checking this box and submitting this application, I confirm that the information provided is accurate and complete. I understand that these services are intended for individuals with financial limitations, and I agree to provide proof of residency and income or government assistance, as required.

Typing your name serves as signature