New Jersey Department of Health

Infectious and Zoonotic Disease Program

Animal Population Control

P.O. Box 369

Trenton, NJ 08625-0369

VETERINARIAN CO-PAYMENT FEE SUBMISSION

Name and Address of Veterinary Hospital

Co-Payment for (Month/Year)

Vendor Identification Number (9 digits)

- 00

Quantity	Type	Fee	Total
General Public Assistance Surgeries	x $10.00 =	$
Shelter Adoption Surgeries	X $20.00 =	$
Total Co-Pay Amount:	$
For reimbursement of surgeries, submit the original Application and Consent for Sterilization of Pets (APC-5) form for each surgery along with an original plus two (2) copies of the State of New Jersey Payment Voucher (APC-7) form to attention of the Animal Population Control Program, at the address shown above.

Completed By (Name and Title)

Telephone Number

Signature	Date

APC-4

AUG 13

Veterinarian Co-Payment Fee Submission, APC-4

IZDP, APC, animal population control, veterinarian, co-payment, copayment, fee, submission, APC-4, EEOH,

ewhite

2013-07-29

NJDOH