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Rock County Humane Society P.O. Box
186, Janesville, WI 53547
Name:________________________________________________________ Address:____________________________________ City:_____________________________ State:__________ Zip:___________________ Phone:__________________________ Do you participate in any of the following public assistance programs? Please circle any that apply to your family & enclose a copy of your Food Stamp or Medicaid ID card if applicable. Food Stamps Medicare SSI AFDC WIC Other (Explain)__________________ Are you or your spouse employed? No
I Am My Spouse is
Is any one in your household disabled? No
Yes
What is your yearly household income from all sources?__________________
How many people, including yourself, live in your
NOTE: Rock County Humane Society considers each application on an individual basis. If your family has any special financial circumstances you would like us to consider, please attach an additional page explaining your situation. If no additional page is submitted, approval will be based on your yearly income and public aid ONLY. I am applying for assistance for my: How many pets in household?___________________ Female Dog - She weighs ___lbs Female Cat - She weighs___lbs Male Dog - He weighs___lbs Male Cat - He weighs_____lbs Dog's Name:________________ Age:___________ Cat's Name:_________________ Age:________________ Has your Dog/Cat ever had Puppies/Kittens: Yes No If yes how many litters:_________________ Is she currently in heat:________________ Could she be pregnant now? Yes No Signature:___________________________________ Date:_____________________ |