North Florida PAWS, Inc.
Florida not-for-profit corporation with IRS Tax Exemption 501(c)(3)
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SPAY - NEUTER GRANT APPLICATION-Adjust printer to fit application on one page.

CONTACT INFORMATION for North Florida PAWS & Hamilton Humane Society

386-938-4092     www.NorthFloridaPAWS.org      e-mail:  [email protected]

The only “North Florida PAWS’ facility is in Jennings, Hamilton County, on Oak St.,

just off US Highway 41, North, near the Florida-Georgia border at Interstate 75.

Complete the following application for each pet, then call 386-938-4092 or e-mail North
Florida
[email protected]
for further instructions and to arrange an appointment.

Name of Owner_____________________________________________________________________

Day # (    )_____-_________________
   Alternate # (     ) _______-______________                   

Address__________________________________________, ___________________, FL   Zip_____________

E-mail Address___________________________________________________________________

Pet Name___________  Cat or Dog?____  Male or Female?______  Estimate Age______  Estimate Weight_______

Breed________________________  Current veterinarian if any___________________________

Social Security Number ______-____-__________   Drivers License # _____________________

Number of people living in your home?_____#

No of dependents who live with you? ______ # of children under 18 or disabled individuals

$_____________ Monthly household income.  Show all sources including wages from all workers in the home, social security benefits, retirement annuity, unemployment, and child support. 

Check and enter identification number for each benefit you are currently receiving.  Benefits in the name of dependent children do not qualify.

  FOOD STAMPS ID #                                         SNAP (Supplemental Nutrition Assistance
                                                         
Program) or WIC (Women, Infants, and Children)

OR

  SSI  ID #                                                   (Supplemental Security Income managed
                                                               by the Social
 Security Administration) 
OR

  MEDICAID (not Medicare) ID #                                                           .

I certify that I have answered all of the above questions honestly and completely.

 

__________________________________________________      ___________________________

SIGNATURE OF PET OWNER                                    DATE


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