Wasaga Beach Cats.pages - Georgian Triangle Humane Society

This section must be completed by each adult related by blood, marriage or common-law relationship living in the household.
To apply for the program:
Where to send applications:
Complete the form included with this brochure. For
assistance with completing this form, call GTHS at
705-445-5204.
Scan and email, mail or drop off the application with
supporting documentation to:
If any personal information changes, please call
705-445-5204 or email [email protected].
Please check all that apply:
What is the best day and time to reach you?
Mon
Morning
Tues
Afternoon
Wed
Evening
Wasaga
Beach cats
A Spay/Neuter
Assistance Program
Wasaga Beach Cats Program
Georgian Triangle Humane Society
549 Tenth Line
Collingwood, ON L9Y 0W1
Phone: 705-445-5204
Email: [email protected]
Website: www.gths.ca
Thurs
Fri
Sat
Sun
What is the best way to reach you?
Ph: ___________________________________
E-mail: ________________________________
Before sending your application, remember to:
• Fill in all sections of the application form.
• Complete the Consent Form acknowledging
that you are submitting your Canada Revenue
Agency Notice of Assessment
• For each adult in the household, provide a
copy of the current official Canada Revenue
Agency Notice of Assessment showing total
income (line #150).
04-12-2013
The Wasaga Beach Cats program provides
financial assistance to Wasaga Beach
residents to spay or neuter their cat.
This program is brought to you by:
Spaying/Neutering will:
To be eligible:
Help your cat live a longer and healthier life
Keep your cat calmer and content to stay at home
Keep your cat from having unwanted babies
Help to decrease the number of unwanted cats going
into the GTHS Animal Shelter each year
• Help our community work towards the goal of no
homeless or unwanted cats
Please complete all of the fields below to ensure proper processing of
your application.
• The applicant must be at least 18 years of age and be
a resident of the Town of Wasaga Beach.
A. Applicant Information
•
•
•
•
First Name:
The Applicant AND each adult related by blood,
marriage or common-law relationship living in the
same household MUST provide the following
documents:
• The family household annual before-tax income must
be no greater than the Statistics Canada Low Income
Cut-Offs (LICOs). Proof of eligibility is required.
___________________________________
• The applicant must be able to pay the $75 fee.
Address:
Canada Revenue Agency Notice of Assessment
For each adult in the household, provide a copy of the
current, official Canada Revenue Agency Notice of
Assessment showing total income (line #150).
Last Name:
___________________________________
___________________________________
___________________________________
City:
Postal Code:
Wasaga Beach, ON
CONSENT FORM:
__________________
Primary Ph:
Cats eligible for spay or
neuter surgery:
• Healthy cats between the ages of 5 mths and 7 yrs
To qualify for this spay/neuter assistance program, the family
annual household income must be no greater than the
Statistics Canada Low Income Cut-Offs (LICOs) as outlined in
the far right column below.
• Must be a healthy body weight
• Must have sound health, therefore not coughing,
sneezing, congested etc.
________________ __________________
LICOs**
1
$18,246
2
$22,714
3
$27,924
4
$33,905
5
$38,454
6
$43,370
NOTE: The applicant must also have a carrier for transport.
$48,285
*Total family members in household includes the number of adults and
dependent children living in the household.
**SOURCE: Statistics Canada Table: Low income cut-offs Table 2 (1992
Base) before tax for economic families and persons not in economic families,
2013.
Cats not eligible for spay
or neuter surgery:
• Unhealthy or contagious cats. This includes cats that
are coughing, sneezing, have watery eyes, runny
noses, mange or ringworm.
• Nursing cats. Spay 4 weeks after the litter has been
weaned.
Any items that arise due to post operative
complications will NOT be covered in this program.
2) A signature from EACH ADULT in the household is
required on the back of this panel. Please be sure
to include your first name, last name, signature
AND DATE in the fields provided.
Email:
___________________________________
B. Current household family members: all persons living
in the same household and related by blood, marriage,
common-law relationship or adoption.
# Adults
• Must NOT be noticeably pregnant
Total family
members in
household*
7+
• Female cats in heat
1) Please check off both boxes below.
Alternate Ph:
# Children
(under 18)
I hereby consent and acknowledge that:
Total # in
Household
I (we) have enclosed a copy of the previous year’s Notice of Assessment form Canada Revenue Agency for all income earning
residents residing in the household for the
purpose of assessing eligibility for the Spay/Neuter Assistance Program.
C. Number of cats to be spayed or neutered: ___________
You only need to submit ONE application form if you have more than one cat.
D. Signature
______________________ ____________
Applicant’s Signature
Date (DD-MM-YYYY)
______________________ ____________
Witness’ Signature
Date (DD-MM-YYYY)
The personal information collected via this form is being collected under the authority of section 33 (c) of
the Freedom of Information and Protection of Privacy (FOIP) Act. The information will be used for the
purpose of determining eligibility for participation in the Wasaga Beach Cats Spay/Neuter Assistance
Program. If you have any questions regarding the collection and use of this information, please contact
the Georgian Triangle Humane Society at 549 Tenth Line, Collingwood, ON, L9Y 0W1, or phone
705-445-5204.
I (we) understand that if I (we) wish to withdraw this consent, I (we) must do so in
writing to:
WASAGA BEACH CATS PROGRAM
Georgian Triangle Humane Society
549 Tenth Line
Collingwood, ON L9Y 0W1
Ph: 705-445-5204
Email: [email protected]