Humane Society of Wilkes

P.O. Box 306 N. Wilkesboro, NC 28659

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Application for Assistance Your Name: Mailing Address: City, State, Zip: Home Phone: Work Phone My pet is a : Male Female My Pet is a : Dog Cat What is your pet's name? What color is your pet? What is your pet's age? What breed is your pet? What is your pet's weight? Is your pet pregnant? Yes No Tell us about you: Annual Household Income < $5,000 $5,000 - $15,000 $15,000 - $25,000 $25,000 - $40,000 $40,000 - $50,000 >$50,000 Financial Assistance None Public Housing WFFA Medicaid not SSI Food Stamps Reduced Lunch Fees Number of children in household 0 1 2 3 4 5 >5 Number of adults in household 1 2 3 4 5 >5 Case Worker's Name Case Work's Phone # Approved Applicants will receive voucher worth a minimum of $10.00 toward the spay or neuter of their pet. Availability of vouchers is dependent on the availability of funds to cover this program. Limit 3 vouchers per calendar year per address. Applicants must be residents of Wilkes County, North Carolina. Website Designed and Copyrighted © by PC Source Inc.