"FIXES FOR FREE" GRANT APPLICATION Made possible by a grant from the Maryland Department of Agriculture . OWNER'S INFORMATION Name* Street Address* City/State/Zip* Phone Number* Alt. Phone Number Email Address* INCOME ELIGIBILITY INFORMATION Annual household income for ALL members of the household: Number of persons in household: Are you retired?yesno OR Do you or anyone in your household collect (Check all that apply): DisabilitySSIUnemploymentFood StampsWelfareMedicaidWICSection 8 housing You will need to provide proof of either your household income or any government assistance that you receive. Please attach a copy below: ANIMAL INFORMATION Please list all pets that you are requesting assistance for: 1. Pet's Name* femalemale Species: catdog Breed: Age: 2. Pet's Name femalemale Species: catdog Breed: Age: 3. Pet's Name femalemale Species: catdog Breed: Age: 4. Pet's Name femalemale Species: catdog Breed: Age: If any of the animals listed above have current vaccination records or are microchipped, please provide that information along with this application. Once your application is approved you will be notified via your contact information. I agree to indemnify and hold The Humane Society of Kent County MD, Inc. harmless from and against any and all liability arising from the performance of any of the procedures necessary to spay or neuter my pet(s). Name* Date* Check here to indicate that you have read and agree to the terms above.