Angel Fund Application Name A Veterinarian of our choice must receive an approval letter by the Angel Fund Coordinator before the appointment for services to be provided. Who qualifies for Angel Fund veterinary financial assistance? The pet and owner are residents of Yamhill County, Oregon. The pet has been spayed or neutered. If not, the owner is willing to get their pet spayed or neutered prior to or at the time of veterinary service. Unfortunately, Angel Fund cannot be used to assist with the cost of spaying or neutering a pet. However, we can provide several low cost options for getting your pet spayed or neutered, including our own Spay/Neuter Clinic. The applicant must prove that their income is below the federal poverty level or are currently receiving government/public assistance. Evidence of receiving government assistance is generally provided in the form of an award letter that shows a) the owner’s name, and b) the time period the benefits are good for (i.e. the benefits are currently being received). Please note: an ID Card cannot be used as evidence for receiving governmental assistance. Requirements for using Angel Fund: After applicant has been approved by the Angel Fund Coordinator, an email must be sent by the coordinator to the veterinarian prior to service. Angel Fund cannot be used to cover veterinary expenses for exams/procedures that have already occurred. The applicant must also have approval before any follow up care. The Angel Fund Coordinator may send the applicant and their pet to a different veterinary hospital than the applicant’s regular vet. Pet owners are required to contribute to the cost of their pet’s medical care in the form of a co-pay. This co-pay is approved by the Angel Fund Coordinator and paid directly to the veterinary clinic at the time of the appointment (it cannot be provided later). Angel Fund may not pay for all recommended procedures or tests. We try to make Angel Fund available to as many pets and owners as we can. So, we may choose not to include procedures or tests that we feel are not medically necessary. The owner may choose to pay for those procedures/tests themselves, if they wish (this would be in addition to the required Angel Fund co-pay). Angel Fund does not cover specialty surgeries, diagnostic tests, or long-term medical needs like prescription diets or medications (although we can cover the initial portion of medication/food if the diagnosis is part of an Angel Fund approved exam). Angel Fund does not cover regular medical treatments such as wellness exams, vaccines, or spay/neuter surgeries. We also do not cover pest control treatments such as fleas, ticks, ear mites, or worms (unless the infestation has resulted in an urgent or emergent medical condition). Many of these regular maintenance treatments are available at low cost at our Spay/Neuter Clinic. In order to provide funding for as many pets as possible, there are limitations on how much financial assistance an owner can receive. The maximum number of times within a year that a pet owner can apply for Angel Fund is twice (whether for a single pet or for multiple pets). If you are unsure whether you will qualify for or be able to meet the requirements for using Angel Fund, you should complete and submit the application! I have read and understand the eligibility criteria used in making decisions about Angel Fund and the requirements for using Angel Fund if my application is approved. Please answer the following questions about yourself, your pet, and your current situationPet Owner Information First Name * Last name * Address * Address 2 City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Email Address Please provide email address for quicker response Phone * Are you currently homeless? Yes No Pet Owner's Birthdate: Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Owner Financial Information What is your total gross monthly income (include pre-tax money you receive from jobs, Social Security, pension, spousal support, etc.)? Do not include any money you receive from governmental assistance. * Please upload proof of income (e.g. pay stubs): Multi-File Upload You can scan it or take a picture, whatever is easiest. Small files preferred to improve submission speed. Do you have any dependents? Yes No If so, how many? Do you receive any form of government assistance (e.g. SNAP, OHP)? * Yes No Which , if any, of the following forms of government assistance are you currently receiving? Supplemental Security Income (SSI) Oregon Health Plan (OHP) Social Security Disability Income (SSDI) Housing Authority of Yamhill County (Section 8) Supplemental Nutritional Assistance Program (SNAP) Unemployment Benefits Temporary Assistance for Needy Families (TANF) Yamhill County Action Plan (YCAP) Women in Crisis (WIC) Please upload proof of current government assistance (e.g. award letter): Multi-File Upload Files can be scans or photos of forms; Item must have name & current dates ; evidence for only one form of assistance is needed, not all that you are receiving.Small files preferred to improve submission speed. One of the requirements of using Angel Fund is that pet owner’s contribute to the care of their pets in the form of a co-pay. The owner provides the co-pay to the veterinary clinic at the time of their appointment. How much can you put towards your pet’s treatment? * Are you experiencing a recent financial hardship that we should know about? Yes No If so, please describe the circumstances of your recent hardship: Pet Information Pet's Name * Pet Species * Dog Cat Other Pet's Breed(s) * Pet's Coloring * Pet's Age (best guess is okay) * Pet's Sex * Male Female Pet's Birthdate (if known): Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Is your pet spayed or neutered? * Yes No If no , would you be willing to get them spayed/neutered? Yes No Upload photo of pet Pet's Medical Information What veterinary clinic(s) has your pet been seen at before? * Briefly describe your pet’s health concern that has brought you to Angel Fund * Does your pet have any pre-existing medical/situational/psychological conditions that might be useful for us or the vet to know about? Please explain. * Additional Information Is there any other information you would like us to know? If so, please describe. One of the ways that we can help people and pets in need, is by telling our donors stories about the pets we have helped. We would like your permission to use your (and your pet’s) story to raise funds for Homeward Bound Pets and Angel Fund. Your answer to this question WILL NOT affect our decision about your application. Can we use your information in our fundraising endeavors? * Yes No If yes, please check what information about you and your pet you would be comfortable with us using (please check all that apply)* Our story My first name (we will never use your last name) My pet’s name Photos of my pet Photos of me and my pet Submit Your Application By typing my name below and submitting this application, I certify that the information I provided is true and correct to the best of my knowledge. I also agree to the conditions for receiving assistance from Angel Fund and requirements for using Angel Fund that were described prior to the application. Applicant's Name: Submission speed may be impacted by the size of uploaded files. Please be patient while files are uploaded. Contact Angel Fund at email@example.com or call 971-261-0709 to leave a detailed message. An Angel Fund Representative will contact you to go over your application.