Spay/Neuter Application

First Name*

Last Name*

Phone Number*

Address*

City*

State*

Zip Code*

Email Address*

Pet Food Bank ID

Alternate Phone Number

How did you learn about our program?

Age*

Have you had a pet spayed/neutered through our low cost program in the past?

Additional Information, Comments or Questions

Current Veterinarian

Are you a Pet Food Bank Recipient?

Pet Information

Please complete this information for each pet. You can add additional pets by clicking on the "Add New Entry" link.

If you pet is current on their vaccinations, please answer "Yes" in the vaccinated column. If they are missing a vaccination or you are not sure, please answer "No".

A Type	B Name	C Breed/Description	D Sex	E Age	F Weight	G Vaccinated

Add New Entry

After you submit this form, our volunteers will review your application and confirm that you qualify for our program. You may be contacted to clarify your information. While waiting to have a voucher issued, we recommend that you get your pet up-to-date on all of their vaccinations. Most veterinarians require that animals are current on their vaccinations before they will complete the spay/neuter procedure. A list of low-cost vaccination clinics can be found on our website.

Once you receive a voucher, it is your responsibility to contact the veterinary office of your choice to schedule an appointment. It is important to discuss the final cost of the procedure with your vet of choice before confirming your appointment. The voucher is issued for the portion of the procedure that Lincoln Animal Ambassadors will pay for - this is not the price you will pay!

The appointment must be scheduled before expiration date listed on the voucher. The surgery does not need to be completed before the expiration date. It is also your responsibility to take your pet to the veterinarians’ office for their appointment.

Government Assistance:

Can you print your voucher?*

Please list the members of the applicant's household.

Applicant Household Income :*

Number of people in household :*

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Financial Information

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To automatically qualify for financial assistance, you can provide one of the following:

1. Currently receiving WIC – upload your Statement of qualifying benefit period

2. Currently receiving Medicaid – upload the applicants Statement of qualifying benefit period. Medicaid documentation must be for head of household or applicant, not dependent children.

3. Current receiving Food Stamps (SNAP) – upload your Statement of qualifying benefit period

If you do not have any of the above, you must supply the following in order to be considered for financial assistance.

1. Proof of income – Earned and unearned (gross) income for all persons residing in the home. (Gross income is what you have before taxes or anything is taken out. You can show “earned income” with your paycheck stubs for the past month. “Unearned” income is money you get that is not a pay check. This could be child support or unemployment compensation benefits or disability benefits that you get.

-- OR --

2. If you are self-employed, you must show a copy of last year’s income tax return.

We strictly follow Income Eligibility Guidelines to determine if someone is eligible for assistance.

See the income chart .

Here

Upland Income Verification Documents :

Applicants can upload your financial verification documents with this application using the browse option below. Please include a description of the documents provided.

You can submit your application without providing these documents. You will receive instructions for providing these documents later in the confirmation email.

Documents can also be mailed to:

Lincoln Animal Ambassadors
ATTN: Spay/Neuter Program
P.O. Box 67072
Lincoln, NE 68506

Documents Provided :

I receive government assistance and will provide proof of government assistance when requested.

By checking this box, I confirm the household income I have provided includes the income of all residents living in the home and will provide proof of such income when requested.

By checking this box, I confirm the total number of household members living in my home is correct and will provide proof of household members when requested.

By checking this box, I agree that the information provided is true and accurate. If I have made any false or untrue statements, including suppression or concealment of information, I understand my access to Lincoln Animal Ambassador’s Spay/Neuter Assistance Program will be forfeited. Lincoln Animal Ambassadors will pursue legal action and/or prosecution for providing us with fraudulent information to the fullest extent of the law.