lnstructions:
The Prevent Homeless Pets (PHP) clinic in Benton City, WA is open to qualified low income families, and to caretakers of
stray and feral cats (Stray feral caretakers do not need to meet the income guidelines). PAWS provides transportation to
the clinic several times a month from Pendleton and Hermiston.
lncome Guidelines:
the current WIC income guidelines, copied below (lncome at or below income listed
BEFORETAXES). OR,youareeligibleifyoureceiveanyofthestate/federalserviceslistedonpageL(PHPapplication)
PHP Spay/Neuter clinic uses
Household Size
Weekly income
Bi-weekly income
Monthly income
Annual income
L
2
S+re
560
s831
L,L20
$1,800
2,426
S21,s9o
29,LoL
3
705
t,409
3,051
4
849
1,698
3,677
36,6t2
44,t29
5
993
1,986
4,3O3
5L,634
6
I,L38
2,275
4,929
59,L45
7
L,282
2,564
5,555
66,656
8
r,427
+L45
2,853
6,tBL
74,L67
+289
+626
+75Lt
Each Additional:
cLrNrc
All of the following information Ís required unless
otherwise specified.
Pnevent lHlomeless Pets
Print Your Street Address
Cl.ftnúc
PHP provides low cost spays and neuters
for both
dogs and cats. Our service is limited to two
designated groups.
Group L:
Rescues, Shelters, and Caregivers.
Caregivers are persons who
provide food and water for
feral/stray animals living in a
colony (group).
Grouo
2:
City
zip
State
Your Phone Number
zation
I certify all statements made in this application
are true, complete, and correct to the best of my
knowledge, and that any misrepresentation or
omission shall be considered sufficient cause for
disqualification of assistance.
Print YourName
Spay & Ner.tter
Release of Authori
I authorize your agency to contact any sources
necessary to establish accuracy of the information
given by me. I also certifu that the pet(s)
receiving surgery is/are my own and I am the
Your Cell Number
Print Your Email Address
legal owner of the animal(s).
How many people are currently living in your
household? Adults:
Children:
I understand that completing this application does
not guarantee my pet will be provided assistance
through this program and participation is at the
discretion and approval of prevent Homeless pets.
Total household income - monthly or annually; indicate which
Please check any assistance you or anyone
Pets of "low-lncome" households.
If you believe your household would qualify
fill out this
application and submit the completed form to
our offices or email it to us at the email address
listed below. Information will be verified.
currently
living in your home is receiving.
(Information will be verified)
tr Food Stamps
D Section g Assistance
Signature
Date
as a "low-income" household please
Appointments will be scheduled AFTER your
application has been approved.
Do you have reliabletransportation to get to and from your veterinary
appointment?
you currentl¡ or have you in the past years visited a local veteriÁarìan?
!o
5
If yes, what is the name of the veterinarian clinic?
Please check the information that applies to your
tr
D
(female) D
tr Spay (female) tr
Spay
DD og
D Cat
tr Spay (fema
tr
ECat trS pay (female ) !
EYes trNo
DYes DNo
pet(s). one line per pet.
N euter
(male)
Age:
Approximate weight of the animal
Neuter
(male)
Age:
Approximate we ight of the animal:
Neuter (mal e) Age
Neuter (male)
Age
Revision 3/6i l4
Prevent Homeless Pets (PHP) Release Form
PHP is a non-profit 501(cX3) agency approved by the Internal Revenue Service. Donations are tax deductible
Demographics:
Phone:
Name:
Email
Address:
Gender andage of person feeding
cat: E Male
Age:-
Is this person on financial assistance?
Occupation:
Carrier
E Female
Cat[Dog
CC or PHP Color/Breed/SH MH LH
Age Gender Feral
KorA M,F,or? ET
Tame
NET
E Yes
Shots
315-way Rabies
Test
trNo
#
Felv/FIV Tag
V/e will take every precaution possible to care for your cat or dog in a responsible manner while s/he is in our
possession. If the vet determines that it is in the best interest, health-wise, for the animal to be euthanized, it
will be done. Owners/Caretakers are responsible for any illness developing after surgery. By signing this form
you release Prevent Homeless Pets and its subsidiaries, jointly and severally, from any liability resulting from
accidental loss, injury, illness or death of your cat or dog.
Signature
Date
PHP
Animal lnformation
Your Name
Pets
will be transported by PAWS to Prevent Homeless Pets, a spay/neuter
clinic in Benton city, washÍngton (iust past Tri-cities).
Animal's information
Animal's name:
Dog or Cat?
Male or Female or Unknown?
Approximate age:
Color/markings:
For dogs, Breed?
Length of hair (short/medium/long)
current rabies shot?
(certificate or tag, if no, they will
get a rabies shot at the clinic for 55, this is a requirement of the clinic)
Do you have proof of
Do they need the combination vaccine?
(usually given yearly in adults, includes distemper for cats and parvo for dogs)
will you be bringing
(The crate needs
a crate (hard sided) that your animal can ride in?
to be large enough for your animalto lie down comfortably.
PAWS can provide a crate
needed.)
Cats onlv:
lf they find fleas, would you like the clinic to treat for fleas?(no exrra charge)
Tame or Wild?
Ear tipped
(yes/no)?
pet cats only if requested to receive the lower feral price)
(feral/wild cats get ear tipped,
if