Angel Fund Application

Please verify before continuing. *

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 verify before continuing. *

I verify that I live in Yamhill County, Oregon

Applicant Information

First Name *

Last Name *

Please note: you MUST live in Yamhill County, Oregon to be eligible for Angel Fund Veterinary Financial Assistance. *

Yes! I live in Yamhill County, Oregon.

Address *

Address 2

City *

State *

ZIP *

Email Address *

Phone Number *

Pet Owner's Birthday *

Are you currently homeless? *

Yes

No

Applicant 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). You can scan it or take a picture, whatever is easiest.

Choose File

Do you have any dependents?

Yes

No

How many dependents? *

Please check which, if any, of the following forms of government assistance are you currently receiving? *

Supplemental Security Income (SSI)

Social Security Disability Income (SSDI)

Supplemental Nutritional Assistance Program (SNAP)

Temporary Assistance for Needy Families (TANF)

Oregon Health Plan (OHP)

Housing Authority of Yamhill County (Section 8)

Unemployment Benefits

Yamhill County Action Plan (YCAP)

I don't receive any assistance.

Other:

Please upload proof of current government assistance (e.g. award letter, not your card you carry with you): (Files can be scans or photos of forms; Item must have name and current dates; evidence for only one form of assistance is needed, not all that you are receiving)

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A requirement of using Angel Fund is that the pet owner contribute to their pets care in the form of a co-pay. How much can you put towards your pet’s treatment? * *

Are you experiencing a recent financial hardship that we should know about?

Yes

No

Please describe the circumstances of your recent hardship:

Pet Information

Pet's Name *

Pet's Birthday (if known)

Pet's Species

Dog

Cat

Other:

Pet's Age (Best guess is ok) *

Pet's Sex *

Female

Male

Pet's Breed(s) *

Pet's Coloring *

Is your pet spayed or neutered? *

Yes

No

If no, would you be willing to get them spayed/neutered? This is an Angel Fund Requirement. *

Yes

No

Upload a picture of your pet.

Choose File

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 me and my pet

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 *

Please be patient after submitting - it may take a moment to upload any files you are including.

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