Animal Services - Love Me, Fix Me Access Program Application

Love Me, Fix Me Application

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

 

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.

 

A dog license is required and may be purchased on the day of surgery.

 

Owner Information

* = Required Field

Animal 1

1. Dog or Cat
The co-pay due at the time of surgery is based on the actual weight of your pet at the time of surgery. As such, the co-pay amount is subject to change.
1. Gender

Animal 2

2. Dog or Cat
The co-pay due at the time of surgery is based on the actual weight of your pet at the time of surgery. As such, the co-pay amount is subject to change.
2. Gender

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.

Eligible Programs

Qualifying Documentation

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

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.