Holly’s Place
P.O. Box 455
Lawrenceburg, KY 40342 

Spay/Neuter Assistance Application (print and mail to above address)

(also the Feral Cat Trap/Neuter/Release Assistance Application—these are separate programs and qualifications for each differ)

The following application is required in order to receive assistance in paying for a feline or canine spay or neuter.  Please print legibly and return to the above address.  Please understand that the personal information requested will allow us to decide how much assistance to give you per animal.  This will make our spay/neuter fund go as far as possible, and hopefully decrease the number of animals euthanized in this county. 

Name _________________________ Address ____________________________________ 

Daytime Phone # ____________________ Evening Phone # _________________________ 

Cell # _________________________ Email ______________________________________ 

What is your combined total household income? ___________________________________ 

How many human dependents do you have? ______________________________________ 

How many animals do you have?  ______________________________________________ 

How many and which ones (m/f, cat/dog) still need to be spayed or neutered?   

__________________________________________________________________________   

If dogs, please list weight of each ________________________________________________

How much money are you able to contribute toward the surgery? _____________________ 

If you are caring for a feral cat colony and doing TNR, where is the colony  

located?  __________________________________________________________________

If chosen to receive assistance, this document becomes a contract.  By signing this document, you are certifying that the above information is accurate. 

Signature ________________________________________  Date ____________________

Do not write below this line; for internal use only.
Approved ___________ Co-Pay Amount ___________ Vet ____________________________
Date Contacted by: post card ______________ phone ____________ email ______________
Co-Pay Received Date _____________________ Vet Contacted Date ____________________
Notes ______________________________________________________________________