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Application for Reimbursement of Spay/Neuter Services this form used for surgeries performed after October 1, 2013 Name of City or County: fear: Place a checkmark the Quarter for which you are seeking reimbursement: ❑ January —March ❑ April—Rine ❑ July — September ❑ October — December application must be postmarked application must be postmarked application must be postmarked application must be postmarked by the last day of April by the last day of July by the last day of October by the last day of January Amounts requested for reimbursement Costs associated with spays Costs associated with neuters cats: # of spays cats: # of neuters Total amount: Total amount: $ dogs: # of spays dogs: # of neuters Total amount: $ Total amount: $ A detailed list of each procedure and cost must accompany this form.. name of person that completed this form: contact telephone number: NOTARY PUBLIC CERTIFICATION signature of city or county manager print name of city or county manager date The inrormation detailed on this form has been reviewed by me or my designee and 1 vouch for its accuracy and validity I or my designee verity that each owner met the eligibility requirements set forth under GS 19A -63 (b). We maintain records demonstrating proof in the event of an audit, mailing address: Spay Neuter Program 1030 Mail Service Center Raleigh, NC 27699 -1030 I, as a Notary Public of the said State and County, do hereby certify that personally appeared before me and executed the foregoing information. Witness my hand and seal this day of 20 Signature of Notary My commission expires street address: Spay Neuter Program 2 West Edenton Street, Room 348 Raleigh, NC 27699 -1030 Attachment number 3 State of:. County of F -1 Page 44