FEED THE FAMILY PET ASSISTANCE APPLICATION
Twin County Humane Society
[Counties of Carroll, Grayson & City of Galax]
Mail to: TCHS, P. O. Box 125, Hillsville, VA 24343
ATTN: Feed the Family Pet
Helpline Number: (276) 728-4038
[TOTAL FAMILY INCOME MUST BE LESS THAN $25,000]

DATE ____________

NAME________________________________________________________________________
LAST FIRST MIDDLE MAIDEN NAME

STREET ADDRESS __________________________ APT# ____________

CITY ______________________________________ STATE_______ ZIP ________________
Directions to home: _________________________________________________________________________________________________

_________________________________________________________________________________________________

Home #____________________ Cell#_________________ Email Address: _____________________

SPOUSE or OTHER INCOME PROVIDER IN HOME: _____________________________________________________________________________
LAST FIRST MIDDLE

PET INFORMATION
Total NUMBER PETS IN YOUR HOUSEHOLD: Dogs--______; Size: Small___ Medium___ Large___ Cats ____
Do your pets live inside or out? _______________________________________________________________________

Approximately how much do your pets eat in a month? Dogs______________________ Cats_____________________

APPLICANT’S EMPLOYMENT
COMPANY NAME ____________________________________
___________________________$__________________________
YOUR TITLE/DEPT GROSS MONTHLY INCOME

EMPLOYMENT OF SPOUSE OR OTHER INCOME GENERATED IN HOUSEHOLD

COMPANY NAME ____________________________________

___________________________$__________________________
TITLE/DEPT GROSS MONTHLY INCOME

OTHER INCOME OR ASSISTANCE (gov’t aid or any other)
SSI, Food Stamps, Disability, ETC. _______________________

Total GROSS MONTHLY INCOME: _______________________

I HEREBY GIVE THE TWIN COUNTY HUMANE SOCIETY, INC. THE CONSENT AND AUTHORITY REQUIRED TO COMMUNICATE WITH ANY OTHER PERSONS OR PARTIES CONCERNING MY HISTORY FOR THE PURPOSE OF VERIFYING THE INFORMATION ON MY APPLICATION.
I ALSO GIVE TCHS PERMISSION TO VISIT MY HOME IF NEEDED.

APPLICANT: _____________________________________________________________________________

CO-APPLICANT: _______________________________________________________Date_______________

Please have some type of container to put your pet food in