Applying For Assistance

I have read and agree to Paws 4 A Cure's guidelines, policies and procedures.
I understand that Paws 4 A Cure CANNOT assist with charges incurred prior to approval of application.
I understand that Paws 4 A Cure CANNOT pay for diagnostics (testing).
I understand that Paws 4 A Cure does not pay for spaying/neutering, vaccinations or euthanasia.
I understand that the maximum grant amount if approved for assistance is $500.

I have added info@paws4acure.org into my email address book as a safe contact.

DO NOT COMPLETE THE ONLINE APPLICATION UNTIL YOU HAVE ALL OF YOUR REQUIRED DOCUMENTATION GATHERED AND READY TO BE EMAILED.

YOUR INFORMATION

Your First and Last Name:

Date of Birth:

Street Address:

City:

State:

Zip Code:

Email Address:

Confirm Your Email Address: *REQUIRED

Contact Phone #:

Your Employer Name:

Your MONTHLY net income:

Marital Status:

PLEASE SELECT
Single
Married
Domestic Partner (live with significant other)
Separated
Divorced
Widow

Spouse/Domestic Partner's First and Last Name:

Spouse/Domestic Partner's Date of Birth:

Spouse/Domestic Partner's Employer:

Spouse/Domestic Partner's total MONTHLY net income:

Living Situation

PLEASE SELECT
I live alone
I live with spouse/domestic partner
I live with my spouse/domestic partner and children
I live with my child(ren)
I live with my adult child(ren)
I live with a roommate(s)
I live with my parent(s)
I live with my furchild

How many adults (over 18 years of age) are in your home?

PLEASE SELECT
1 - Yourself
2
3
4
5 or more

How many children (under 18 years of age) are in your home?

PLEASE SELECT
1
2
3
4
5 or more

** (REQUIRED) NAME and BIRTH DATE of EVERYONE living in the home:

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Is your total household income normally above poverty level? If you are unsure, please click on the link above for "Federal Poverty Guidelines".

Yes
No

Do you own or rent your home:

PLEASE SELECT
Own
Rent

Monthly Rent/Mortgage:

Please select the statement that applies to your normal financial situation:

PLEASE SELECT
Recent loss of job (within 12 months)
Major medical diagnosis
Working Poor (101-300% of poverty level)
Senior Citizen
Permanently Disabled (SSDI)
Temporarily Disabled (SSI)
Veteran of the US Military
Other (explain below):

Other please explain:

Please check all that apply to your current financial situation:

I receive child support
I receive alimony
I receive a monthly inheritance
I receive unemployment benefits
I receive disability payments
I receive Social Security
I receive public assistance (welfare, food stamps, etc.)

Unemployment benefits amount received monthly:

Child support amount received monthly:

Alimony amount received monthly:

Disability benefit amount received monthly:

Social Security benefit amount received monthly:

Public assistance received monthly:

If you are claiming temporary hardship, please explain below. (Why you cannot afford the veterinary care. Not about your dog/cat's veterinary care, you will answer about your dog/cat's needs later.)

How did you hear about Paws 4 A Cure?

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About The Dog/Cat

Dog
Cat

Dog/Cat's Name:

Dog Breed:

Age:

Sex:

Male
Female

Spayed/Neutered

Please explain your pet's illness or injury.

Diagnosis (must have a diagnosis from veterinary office)

Please explain the treatment received so far and the initial onset of the illness or injury.

Please explain the treatment still needed:

I have applied for CareCredit:

Yes
No

Were you approved for CareCredit?

Yes
No

Amount approved from Care Credit:

What is the estimated cost of the proposed treatment?

What amount are you able to contribute towards your pet's veterinary care?

What amount are you asking for Paws 4 A Cure's help? (maximum grant is $500)

Is the dog/cat receiving financial assistance from any other organization?

Yes
No

Please list the organization and amount received:

Please provide the link to your GoFundMe page:

Please provide the link to your YouCaring page:

Please provide any other fundraising URL that you have:

Explain in detail how have you been trying to raise money for your dog/cat's veterinary care.

Pet Insurance Company Name:

Policy #:

Contact #:

VETERINARIAN INFORMATION

Treating Veterinarian's Name:

Veterinary Practice's Name:

Veterinary Practice's Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Veterinary Practice's Email Address: