MDA Webforms | Spay-Grant-Application

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Facility Information

Facility Name *

Facility Address *

Address 2

City *

State *

County

Zip Code *

zip plus four -

Primary Phone *

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

ACFA License Number

- Acfa Num Ext

Contact Person

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1 *

Address 2

City *

State *

Zip code *

Zip Code - zip plus four

County

Primary Phone *

Phone Type Ext.

Phone 1

Phone Type Ext.

Phone 2

Phone Type Ext.

Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Describe Agency

Validate Organization Selection

Organization Structure *

City or County Government

Private Nonprofit Agency

Spay/Neuter Clinic

Veterinary Association

Private Veterinary Clinic

Community Collaboration

Validate ServiceSelection"

Service Provided *

Unlimited Intake Shelter

Limited Intake Shelter

Spay/Neuter Services

Animal Control

Feral Cat Sterilization

Veterinary Care to the Public

Other

Attending Veterinarian

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1 *

Address 2

City *

State *

County

Zip Code *

zip plus four -

Primary Phone *

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Validate Discount

Do you have an existing program with your attending veterinarian that includes a lower cost or discounted plan? * Required YesNo Please select Yes or No

Type of Entity

NonProfit Organization

Government Agency

Population Information

What county(ies) does your Spay/Neuter Program cover and what is the population of each? *

Population

County

Cost and Funding Information

Average cost per procedure for the program for which the grant is requested. *

What criteria does your organization use in determining financial needs of individuals? *

What is the target population (E.g. low income, indigent, elderly, shelter animals, etc) intended to served by the program funded by this grant? *

Pet Overpopulation

Describe and quantify, to the extent possible, the pet overpopulation problem in your community using your agency's data and any other meaningful estimates. *

Animal Statistics

For your organization, in the last completed year. *

select dogs and cats for each section

Dogs

Cats

Admitted

Number of Admitted Dogs

Number of Admitted Cats

Adopted

Number of Adopted Dogs

Number of Adopted Cats

Sterilized

Number of Sterilized Dogs

Number of Sterilized Cats

Euthanized

Number of Euthanized Dogs

Number of Euthanized Cats

If your program performs adoptions, are all animals sterilized before adoption? Selection Required * YesNo

Validate sterilized must be with 0-100% range

Previous Program and Resources Information

Does your organization currently have a spay/neuter program? Selection Required *

YesNo

How long has your spay/neuter program been in operation?

Provide the number of procedures performed over the past year by your organization / agency. *

Spays

Neuters

How many animals were spayed/neutered through your organization/agency during the last year? *

Dogs

Cats

Has your organization received a grant from the spay/neuter fund in the past? Selection Required *

YesNo

How many procedures were performed with the grant?

Spays

Neuters

Is this funding planned for expanding or enhancing a program? YesNo

Does your organization shelter animals? Selection Required *

YesNo

What are your adoption fees?

Describe the general socio-economic need (e.g. poverty levels, unemployment, per capita income, occupational data, etc.) of the counties covered by your spay/neuter program. *

Describe what community collaborations, if any exist and how this grant will foster the creation or extension of those collaborations. *

What other resources for spay/neuter assistance exist in your community and who are their target populations? *

If grants from other organizations are anticipated, please tell us from whom and how much has been requested or awarded.

Explain how post-surgical monitoring and care will be managed. *

How would a grant increase the number of spay/neuter procedures in your community? *

Please describe your plan to promote the "I'm Pet Friendly" license plate. * (Attach images to support your plan)

Upload

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Signature

I have read and understand the terms and policies.* Required

Legal Name*

Date 04/25/2026

Spay and Neuter Grant Application