SNIF Voucher Request

Proof of income can be any one of the following combinations. Please be sure to remove or conceal sensitive personal information like your social security number. We do require that the name and address on supporting documents match that of the applicant. 1.) Medicaid Card (adult, not child) and copy of last tax filing. 2.) WIC Card (current date) and copy of last tax filing. 3) Letter granting Social Security Income (adult, not child) and copy of last tax filing.

By typing my name in the box below, I certify that I personally own the animal(s) listed and I understand that copay is due on the morning of appointment. If any other services are requested by myself or the veterinarian that I will pay for those services on the morning of appointment or at time of pick up. As a reminder, the voucher only pays for the spay/neuter surgery, the associated pain medication, and a rabies shot. Any other services offered and/or requested, such as but not limited to bloodwork, vaccinations other than rabies (FeLv, Distemper, Bordatella, etc.), allergy or anxiety medications, heartworm testing, or heartworm and flea/tick preventives, are your responsibility to pay. They will not be covered by PFLNC. I agree that by typing my name in the box below, I agree that it is binding just as if I signed my signature.