Spouse's Name (if applicable)
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Your Employer (Name and Address)
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Your Length of Employment
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Work Phone
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Total household income
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Application for Assistance
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Your Spouse's Employer (Name and Address)
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If request is for medical assistance, how much can you afford to contribute at this time?
Type of assistance requested and reason (please explain)
*
If the veterinarian is willing to offer a payment plan, will you take advantage of this option?
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If no, why?
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Your Name:
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List any Government Assistance
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Check box
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By checking this box, I certify that the above information is true. I understand any pet care assistance I may receive will be provided to my pets based on the information above. I understand in order to receive pet care assistance I must be a resident of Moffat County.
Number of dependents (including self/spouse)
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