HomeMy WebLinkAboutVaccinationSpayNeuter ReimbursementCITY OF PALM DESERT
Animal Vaccination and Spay/Neuter Incentive Program
Reimbursement Request Form
PLEASE COMPLETE THIS SECTION
Name of Individual Requesting Reimbursement:
Telephone Number:
Palm Desert Address:
Mailing Address:
City: State: Zip Code:
I hereby certify that I am a City of Palm Desert resident.
Resident’s Signature: Date:
Does your animal have a microchip? □ yes □ no
If no, would you microchip your animal if it was partially reimbursable? □ yes □ no
PROOF OF ELIGIBILITY OF RESIDENCY
A valid identification (i.e. driver’s license or state-issued ID card), documentation or receipts for the
procedure (vaccinations or spay/neuter), plus one of the following:
Type of procedure: □ New pet vaccinations ($25) □ Routine annual pet vaccinations ($25)
□ Spay/Neuter ($50)
Type of animal: □ Cat □ Dog □ Other
Date Reimbursement Request Form received: Received by:
Amount requested: $ Approved □ Denied □ (Due to residency requirements)
Authorized signature to approve reimbursement:
FOR OFFICIAL USE ONLY
□ Utility bill with your City of Palm Desert address
□ Property Tax Bill with your City of Palm Desert address
□ Your rental or lease agreement with utility bill showing City of Palm Desert address