Part One: Applicant InformationName(Required) First Last Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Additional PhoneEmail Part two: Pet InformationPets Pet 1 Pet Name(Required)Species(Required) Cat Dog Gender(Required) Male Female Age(Required)BreedNotable medical conditions Please note the following costs: Cat Neuter – $45.00 Cat Spay – $75.00 Dog Neuter – $120.00 Dog Spay – $130.00 Adding on vaccinations is additional – $25.00 Please be advised that should any additional costs be incurred during the procedure; those costs are the responsibility of the designated owner. Procedures will be completed at the Swan Valley Veterinary Clinic.Part Three: Confirmation of EligibilityPlease read each statement and confirm you are eligible by checking each one: I am the legal owner of the animal I have above noted. I am a resident of the Swan River Valley – this includes the RM Of Mountain, RM of Minitonas-Bowsman, Municipality of Swan Valley West and the Town of Swan River. My total household income is at or below $40,000. My animal is of age (minimum 6 months or older) for the procedure to be performed. I will provide proof of income as well as proof of residency with my submitted application. I agree that to be accepted for the program the procedure must take place at the Swan Valley Veterinary Clinic in Swan River. Part Four: Proof of Income Each income earner on the application must provide a copy of their most recent Notice of Assessment from Canada Revenue Agency. Before Tax, Line 150 from each form will be added together to determine the total household income. Below, list the people in your immediate family (parents/guardians and their children who are under 19 years of age) that are currently living in your household along with their income (if applicable) from line 150 on the most recent Notice of Assessment from Canada Revenue Agency. This includes a maximum of two adults. Adult children 19 years of age and over, roommates, or other non-immediate family members, such as grandparents, are not to be included within your household numbers for the purposes of this application. They may apply on their own, which will be dealt with as an entirely separate application.Applicant(Required)Last NameFirst NameDate of Birth (MM-DD-YY)Income Level (As shown on Line 150 of most recent Notice of Assess- ment from CRA) Add RemoveSpouse/PartnerLast NameFirst NameDate of Birth (MM-DD-YY)Income Level (As shown on Line 150 of most recent Notice of Assess- ment from CRA) Add RemoveDependants (leave empty if you have no dependants) Dependant 1 DependantLast NameFirst NameDate of Birth (MM-DD-YY)Income Level (As shown on Line 150 of most recent Notice of Assess- ment from CRA) Add Remove Part Five: Declaration of UnderstandingI hereby declare that I am the legal owner of the animal noted above and am above the age of eighteen (18) years old. I agree that I will provide SVAPL with the fee associated with the chosen procedure BEFORE booking my animal in for the procedure. I understand that the procedure will be completed at the Swan Valley Veterinary Clinic and that it is my responsibility to ensure that my animal is there on time on the date of the procedure. I understand that any additional costs incurred during the procedure above the agreed upon fee are my responsibility. I understand that if anything should happen to my animal while participating in the program (eg, injure itself, become ill or die), SVAPL will not be held responsible. I understand that the veterinarians involved with the procedure have the right to refuse my animal for medical reasons. If the animal is deemed unfit for the procedure by the overseeingveterinarian, the procedure will be cancelled and SVAPL with be notified so arrangements for a refund can be made. I understand that should I miss the appointment without notice and without valid reasoning to SVAPL and the Swan Valley Veterinary Clinic, I could lose my payment and could have my application from the program revoked at SVAPL’s discretion. I understand that SVAPL has the right to refuse service should it be determined that I have been untruthful in any of the above noted information. I understand that I will NOT be contacted if I have been denied for the program. I understand that if I do not provide all the required documentation at the time of my application submission; I could be denied for the program.Certify(Required) By checking this box, you are agreeing to the terms of this document.If you have questions or concerns regarding the Subsidized Spay & Neuter Program, please call 1-888-212-6385 or email *protected email*. SVAPL Spay-Neuter Program reserves the right to verify information provided on this application form. If submitting online, please upload all required documents with submission. If you are mailing the application, please send to: SVAPL Box 2735 Swan River MB R0L 1Z0 Required Documents: Subsidized Spay Neuter Program Application Form Income Verification: copy of most recent Notice of Assessment from CRA Proof of Residence: this can be a utility bill from the last month or a land tax billRequired Documents Drop files here or Select files Max. file size: 32 MB, Max. files: 3. Proof of Income & Proof of Residence