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-1 <br />THE X20 FIX: AnimalKind's Financial Assistance Program for Pet Spay/Neuter <br />Your Name: Where did you get this application? <br />Mailing Address: City: State: Zp: <br />Street Address (if different from your mailing address): <br />City: State: Zp: In what courrty do you live? <br />Daytime Phone: Evening Phone: E-mail: <br />Your Age: Number of Adults in Household (induding you): Number of Children in Household: <br />Only in extreme dreumstances, AnimallGnd may be able to reduce the $20 co-pay (the amount you pay). ^ YES, have someone contact me about <br />reducing the co-pay. <br />Please enclose EITHER a copy of your Medicaid card OR a copy of the last tax return for each adult in your <br />household. If you quality based on your current income (see bads side of application) but did not file taxes, please enclose a note of explanation <br />and your best proof of income (W-2's, check stubs, etc.). <br />Are you endosing a copy of your own Medicaid card? Yes No <br />Are you endosing a copy of the last tax return for each adult in your household? Yes No <br />Current household income per month from all sources (the amount before taxes are taken out): <br />Please list any assistance programs from which your household gets help: <br />Important note about privacy: The information you provide will not be sold or shared. For additional protection of your private information, please <br />mark through the Sodal Security numbers on all copies of documents before mailing them. Do not send original documents! <br />Please list your pets that need spaylneuter surgery: <br />We cannot issue vouchers for feral or stra cats or do s. Contact us for other resources. <br />Pregnant? In Heat? Approx. Approx. <br />Dog or Cat Pet's Name Sex Description or Breed Age Weight <br />I understand that THE;20 FIX vouchers are for pets owned by me-the applicant. The information I have provided about myself, my pets, and <br />my household income is accurate and truthful. I have enclosed a photocopy of my Medicaid card or the best proof I have of my total <br />household income. Fraudulent use of THE S20 FIX program will result in services charged to me at full price and possible legal action against <br />me and others involved in the fraudulent use of vouchers. <br />Signature: Date: <br />Please mail completed application to: THE;20 FIX, P.O. Box 12568, Raleigh, NC 27605. If you need help filling out the application, please call <br />919-870.1660 ore-mail: thefa~animalkind.oro. Please do not mail payment with application. <br />(Office use only-Farm 9-22-08) Reviewer: Da#e Approved Denied Professional Referral (NamelPosition/Contact Info): <br />