Voucher Application 73050 SAFAVoucher

User Manual: 73050

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SANTA ANA FRIENDS FOR THE ANIMALS (SAFA)
SPAY/NEUTER VOUCHER APPLICATION
Name

Date_______________

Address__________________________________

Santa Ana, CA. Zip Code________

Hm. Phone#____________________ Day Time Phone# ___________________

Animal Name__________________Cat_______Dog_______Breed_____________Color_________________ Sex: M / F (circle one)
Age____________ Weight_______________ Pregnant: Y / N (circle one)

Dog License # if any_________________

Our funding providers require that we collect the following information; this information will not affect your eligibility for a voucher.
Household Size  one
Household Income  one that corresponds to household size
1 person

$0-$16,550  $16,551-$27,550  $27,551-$44,050  $44,051 and above 
2 persons

$0-$18,900  $18,901-$31,500  $31,501-$50,350  $50,351 and above 
3 persons

$0-$21,250  $21,251-$35,400  $35,401-$56,650  $56,651 and above 
4 persons

$0-$23,600  $23,601-$39,350  $39,351-$62,950  $62,951 and above 
5 persons

$0-$25,500  $25,501-$42,500  $42,501-$68,000  $68,001 and above 
6 persons

$0-$27,400  $27,401-$45,650  $46,651-$73,050  $73,051 and above 
7 persons

$0-$29,300  $29,301-$48,800  $48,801-$78,050  $78,051 and above 
8 or more persons 
$0-$31,150  $31,151-$51,950  $51,951-$83,100  $83,101 and above 
Please place a check mark in the appropriate boxes for ALL three questions:
1. Are you Hispanic? Yes  No 

2. Please  one that best describes you:
White  Black/African American  Asian  American Indian/Alaskan Native  Hawaiian/other Pacific Islander 
American Indian/Alaskan Native & White  Asian & White  Black/African American & White 
Amer. Indian/Alaskan Native & Black African Amer.  Multi Racial 
3. Are you a female head of household? Yes 

No 

Our spay/neuter voucher program was created to assist those individuals with limited funding that could not afford the cost normally
associated with spay/neuter. For this reason we do not require a “co-payment”, however our funding is limited, and in order to stretch our
dollars and save as many lives as possible, we request that you contribute what you can afford as a co-payment for the surgery. If you can
help us save more lives please make the co-payment directly to the veterinarian or to SAFA.
Voucher is null and void if declawing, tail docking, ear cropping, or any other mutilation procedure is to be done at the time of spaying or
neutering.
RELEASE AND WAIVER OF LIABILITY
THE SANTA ANA FRIENDS FOR THE ANIMALS (hereinafter “SAFA”) has developed a program whereby I may receive a voucher to
take my animal to a participating veterinarian for free spay/neuter services. (hereinafter “said Voucher Program”)
SAFA is also offering Avid® identification microchips. The cost of the microchip is $24.00 including registration in PETtrac® national
registry and injection by the veterinarian at the time of spay/neuter surgery. MICROCHIP PURCHASE IS OPTIONAL AND NOT REQUIRED to
receive a spay/neuter voucher. If you wish to purchase a microchip please include a check with this application made payable to SAFA.
IN CONSIDERATION of participation in said Voucher Program, I hereby acknowledge, agree and represent the following:
1.

I UNDERSTAND THE SPAY/NEUTER SURGERY AND THE MICROCHIP IMPLANT PROCEDURES HAVE THE RISK OF
COMPLICATIONS, INCLUDING DEATH, TO MY ANIMAL. I HEREBY ASSUME FULL RESPONSIBILITY FOR ANY RISK
OF SICKNESS, INJURY OR DEATH of my animal due to my participation in said Voucher Program.

2.

I understand participation by any veterinarian in said Voucher Program is not a representation by SAFA of that participating
veterinarian’s skills or a warranty of its services.

I HAVE READ AND VOLUNTARILY SIGN THIS RELEASE AND WAIVER OF LIABILITY, and further agree that no oral representations,
statements or inducement apart from this written agreement have been made. I further attest that I am a resident of the City of Santa Ana and the
above listed dog or cat is my pet.
Date

Signature_____________________________ How did you hear about this program?________________________________

SAFA USE ONLY-Representative reviewing/verifying application:
Signature______________________________________

Issue date_______

Spay/Neuter Authorization # ______________________ Microchip Authorized Yes / No Check # _______ or Cash
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Author                          : Leo Novelli
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