Fixes for Free in Kent County Grant

PET OWNER'S INFORMATION

Name*

Street Address*

City/State/Zip*

Are you a resident of Kent County, Maryland: YesNo
Phone Number*

Email Address*

Do you: RentOwn
ACSKC will check property records to ensure ownership
If renting, landlord's name:
Phone

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):
DisabilitySupplemental Security IncomeUnemploymentFood StampsWelfareMedicaidWomen, Infants and ChildrenFederal Public Housing Assistance

**REQUIRED: Please provide proof of either your household income (most recent pay stub or IRS tax return) 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:

If any of the animals listed above have current vaccination records or are microchipped, please provide that information along with this application.

How did you hear about this grant?
The Shelter’s WebsiteNews ArticleFacebookInstagram106.9 WCTRFlyer/AdvertisementOther

Once your application is approved you will be notified via your contact information.

I agree that my veterinarian may share the above listed animal(s) medical records with The Animal Care Shelter for Kent County.
I agree to indemnify and hold The Animal Care Shelter for Kent County 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.