Love Me, Fix Me Application

Please review our Love Me, Fix Me program qualifications and requirements prior to completing this application.

The purchase of a dog license (if you live in an unincorporated area or the City of Santa Rosa), driver’s license/picture ID, and proof of address (such as a utility bill) are required prior to receiving a voucher, in addition to proof of low income.

Owner Information

* = Required Field

First Name

Last Name

Email

Street Address

Apartment #

City, State, Zip

Primary Phone

Animal 1

1. Dog or Cat

Dog

Cat

1. Name

1. Age: Years

1. Months

1. Breed(s)

1. Color(s)

1. Gender

Male

Female

Add additional animal

Animal 2

2. Dog or Cat

Dog

Cat

2. Name

2. Age: Years

2. Months

2. Breed(s)

2. Color(s)

2. Gender

Male

Female

Attestation of Household Income and Financial Hardship

Select one method below

In order to qualify for the Love Me, Fix Me program, your household must meet one of the following criteria:

1) I or someone in my household currently participates in at least one of the qualified assistance program(s):

CalFresh/Food Stamps
Free or Reduced Lunch
Medi-Cal
SonomaWorks/CalWorks/TANF
WIC

Or

2) My household's income does not exceed the "very low income" limitations by household size as established by the California Department of Housing and Community Development for Sonoma County. To use this method, please attach a copy of your last tax return that shows gross income and number of household members.

I meet the following eligibility criteria: Value is not selected

Eligible Programs

CalFresh/Food Stamps

Free or Reduced Lunch

Medi-Cal

SonomaWorks/CalWorks/TANF

WIC

Number of Household Members

Annual Combined Income of all Household Members

Qualifying Documentation

If submitting any form(s) containing Social Security Number(s), please block out the numbers(s) so they are not legible.

Qualifying Documentation

Signature

I declare under penalty of perjury under the laws of the State of California, that the above information is true and correct. I understand that this information is kept confidential. I also declare that I have not been convicted within the last five (5) years by any court of law for any violation of this chapter or any other law relating to animals, public nuisance caused by animals, or cruelty to animals in this or any other state.

Applicant Signature

Full Name

Species 1

Species 2

Gender 1

Gender 2

Co Pay 1

Co Pay 2

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Animal Services - Love Me, Fix Me Access Program Application

Love Me, Fix Me Application

Owner Information

Animal 1

Animal 2

Attestation of Household Income and Financial Hardship

Qualifying Documentation

Signature