Initial Qualification Form

Financial Aid provided by Friends & Vets Helping Pets is intended as a supplement to family resources. Grants are made not only to families whose ability to pay veterinary costs is extremely limited, but also to those of somewhat more substantial means, up to 200% of the Federal Poverty Guidelines, who may need only minor subsidy to meet the veterinary expenses. No worthy family should be deterred by financial reasons from making application to Friends & Vets Helping Pets, and families who require aid are encouraged to request a grant. At the same time, Friends & Vets Helping Pets is mindful of our obligation to utilize the limited financial aid funds responsibly and prudently, and therefore we insist that recipients fully merit their grants by a conscientious effort and a positive approach to every aspect of the application process. It should also be noticed that due to those limited funds, not all applicants will receive final approval, even after they receive initial approval. Each application is decided upon individually

Friends & Vets Helping Pets does not discriminate based on owner’s race, color, national origin, sex, age, religion, political beliefs, or disability. If any questions asked on the application ask for such information it is important to note that financial aid will not be decided based on such information.

Please answer the following questions. The more details the better.

Applicant's Full Name:*
Pet's Name, Age and Breed:*
Applicant's Address:*
Street Address Address Line 2 City State ZIP Code
Applicant's Email:*
Applicant's Phone Number:*
How did you hear about us?*
How long have you owned the pet?*
From where did you get your pet?*
Are you being forced to consider euthanasia if you cannot pay for treatment?*
Please explain what is wrong with your pet, including dates of initial onset, veterinary office visits, and the types of treatment your pet has received so far.*
What treatment/medication do you seek:*
We require families to assist in the payment of costs for treatment. We hope that families can provide 10-25% (or more) of treatment costs. Please tell us how much you are able to provide at the time services are rendered.*
To the best of your knowledge, what is the estimated cost of treatment?*
Please tell us who lives in your household. Provide first names, relationship to you, and their age.*
Please provide us the names, ages, and species/breeds of all other pets in the house.*
What is the combined gross yearly income of the applicant(s)? Be prepared to provide documentation upon request.*
Have you, or one of the other applicants, incurred a financial hardship in the past twelve (12) months? Please explain fully and be prepared to show documentation in support of your answer.*
Is your pet spayed or neutered?*
Is your pet microchipped?*
Vet Name
Clinic/Animal Hospital Name*
Clinic/Animal Hospital Address*
Street Address Address Line 2 City State ZIP Code
Clinic/Animal Hospital Phone Number*
Applicant Signature*
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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