Application for Income Eligible Spay/Neuter Fees

Please review our program qualifications and requirements prior to completing this application.

Qualification is income-based. A driver's license/picture ID, and proof of address (such as a utility bill) are required prior to receiving reduced fees, in addition to proof of income eligibility.

About You

*First Name

*Last Name

*Email

*Address

Apt. #

*City

*State

*Zip Code

*Daytime Phone

Alternative Daytime Phone

*Required Field

About Your Pet

DogDog

Cat Cat

Rabbit Rabbit

Female Female

Male Male

*Pet's Name

*Pet's Age

*Pet's Approximate Weight

*Pet's Predominant Breed

*On your pet's scheduled surgery day, check-in is between 7:30 a.m. and 8:15 a.m. With that in mind, which day(s) would be most convenient for you?

Monday Monday

Tuesday Tuesday

Wednesday Wednesday

Thursday Thursday

Friday Friday

*Required Field

Attestation of Household Income and Financial Hardship

Select one method below

In order to qualify for Napa Humane's low income fees, your household must meet one of the following criteria:

Assistance Programs

You or another person in your household is participating in one of these assistance programs:

CalFresh/Food Stamps

CalWorks/TANF

WIC

Medi-Cal

AT&T Lifeline

COMBINED GROSS INCOME

My household's income does not exceed the "very low income" limitations by household size as established by the California Department of Housing and Community Development for Napa County. To use this method, please attach a copy of your last tax return that shows gross income and number of household members. If you do not file income taxes, please submit three months of pay stubs per job per wage earner or use one of the options in Method 1.

*Currently participating in an eligible program *Currently participating in an eligible program

*My household is “low income” *My household is low income

*I do not meet either option *I do not meet either option

*Required Field

Qualifying Documentation

If submitting any form(s) containing Social Security Number(s), please block out the number(s) so they are not legible

*Upload Proof of Income Eligibility

*Upload Proof of Residency

*Required Field

Signature

I declare under penalty of perjury under the laws of the State of California, that the above information is true and correct. I understand that this information is kept confidential. I also declare that I have not been convicted within the last five (5) years by any court of law for any violation of this chapter or any other law relating to animals, public nuisance caused by animals, or cruelty to animals in this or any other state.

Signature*

*Required Field