Name____________________________________________Date________________

1
Fix Your PETS!
WE CAN HELP.
Name____________________________________________Da
te________________ Signature ____________________
___________________________________ Address_______
__________________________________________________
City, State, Zip_________________________________
___________________ Email_________________________
_Phone____________________________ Income for
Household ______________Number in Household
_____________ Total Dogs_________ How many are
fixed?_____________ Total Cats__________How many
are fixed?______________ Pets Name
____________Breed______________Color________Weight
___________Age_______ Male/Female Past
litters? Yes./No Quantity? _____ In heat?
Yes/No Pregnant? Yes/No Can you make a
co-payment of any amount? ________ Please
CIRCLE ALL that apply Low Income
Strays TNRM/Feral Cats Supplemental
Security Income (SSI) Rescued Food
Stamps Medicaid WIC Unemployed
TANF Social Security Disability (SSD) HUD
Section 8 Housing Other___________________
_ For those who cannot afford to fix their pets.
  Pet Prevent A Litter (PALS) of central
Texas P.O. Box 401 San Marcos, Texas
78667www.preventalitter.com (512) 754-PALS