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1250 Cox Avenue, Bainbridge, GA 39819
Adopt a Dog
Adopt a Cat
Need Assistance with a Stray Animal?
Please Contact Animal Control at 229-515-0172.
Address Line 2
District of Columbia
Northern Mariana Islands
U.S. Virgin Islands
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Income and Household Information
Please list all sources of income for the entire household. This includes wages, alimony, child support, social security, etc, whether it is for you, your spouse, children, or other people living in the same house. lf you need additional space, use another sheet. You must submit proof of income by providing copies of the 2009 1040 tax form OR proof of state/federal benefits (social security, unemployment, SSI, medical card, etc.), or any pension benefits. W-2 statements alone will not be accepted.
Source of Income (1)
Monthly Amount (1)
Source of Income (2)
Monthly Amount (2)
Source of Income (3)
Monthly Amount (3)
Source of Income (4)
Monthly Amount (4)
Source of Income (5)
Monthly Amount (5)
Where do you live?
How many children (under age 18) live in the household?
How many adults live in the household?
Have you had other animals sterilized through our program before?
Which veterinarian do you currently use?
Has your cat ever been tested for Feline Lukemia?
Small (1-25 LBS)
Medium (26 to 50 LBS)
Large (51 to 75 LBS)
Extra Large (76 to 100 LBS)
Is pet current on shots?
Where does pet mostly live?
How Many Liters has she birthed?
Is she nursing now?
Age of Litter (in weeks)
Does your pet have any conditions that we should be made aware of(diabetes, heartworm, etc.)?
How many other pets do you have?
Are these pets sterilited?
PLEASE STATE OTHER CIRCUMSTANCES THAT WOULD BE RELEVANT TO YOU RECEIVING ASSISTANCE WITH SPAY/NEUTER OF YOUR PET:
Declaration and Release:
I certify that the above information is true and complete. I hereby authorize the BainbridgeDecatur County Humane society to contact my employer(s) and /or any agent to verify income.
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