Humane Society of North Texas HSNT| Online Voucher Application

Humane Society of North Texas
Attn: Volunteer Coordinator
1840 East Lancaster Avenue · Fort Worth, Texas 76103
817-332-HSNT (ext. 118) · Fax 817-332-2164 · www.hsnt.org

Spay/Neuter Assistance (Voucher) Program

Dear Pet Owner:

We have recieved your request for assistance in having your dog or cat spayed/neutered. HSNT does NOT receive any city or government assistance and can offer programs such as this through generous donations. This program is limited to those people who have the greatest need, therefore we need information and verification to ensure this program can assist those in the most need.

The following questions must be completed to be considered for assistance and proof such as a copy of a social security check stub; workers compensation statement or any official document that can verify your total income.

Your Name: Your Age:

Address: City: Zip:

Telephone: Email:

Place of Employment: Address:

Number of People (including children) in your household: Number of People Working:

Your Total Monthly Income: Total Household Income:

Sources of Income:
Social Security:
Pension:
Workers Compensation:
Spouse's Income:
Unemployment:
Other Income:

How Many Animals do you Own? How Many do you Need Help with?

Dog(s) How Many Male(s): Female(s): Weight of Dog(s): Age(s):

Cat(s) How Many Male(s): Female(s): Age(s):

What Animals Do You Need Financial Assistance in Having Spayed or Neutered:

How Much Can You Pay to Have Your Animal(s) Spayed/Neutered:

Please Remember that we ask that you pay what you can afford to allow our limited funds for this program to be utilized by as many people as possible.

HSNT has a limited capacity to do surgeries on a daily basis. HSNT encourages you to find alternative low cost spay/neuter services in the event that HSNT is not able to assist you. HSNT reserves the right to limit the number of animals assisted per household.

By Checking here you certify that the above information is true and correct. Failure to check here will result in your application not being processed.