EmailMe Form - ALLIE CARES, INC. APPLICATION FOR ASSISTANCE

Today's Date *

MM / DD / YYYY

How did you hear about Allie Cares, Inc? *

Pet's name that needs our assistance *

Gender *

Male

Female

Species *

Dog

Cat

Other

Breed *

Pet's Age *

State if above is month or years

Pet's Weight *

How long have you had this pet? *

State if above is days, months, years

Is this pet spayed or neutered? *

Yes

No

Pet is inside or outside pet *

Names, Species, Breed of other pets in house *

ABOUT YOU

Pet Owner *

First Last

Email Address *

Email where we can reach out to you. We often use email.

Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Name, Ages, and Relationship (to you) of all adults over age 18 *

If none type "none." If other adults in home, type their NAME, AGE and RELATIONSHIP to you for each person

Are you currently working? *

Yes

No

Your occupation at current or most recent job *

Job Title and what you do. If not currently working explain how you spend your time during the week. **If currently military or transitioning from military please advise.

Occupation of spouse/live in at current or most recent job *

Job Title and what you do. If not currently working explain how they spend their time during the week. **If currently military or transitioning from military please advise.

Number of children under 18 residing in the home *

Total household income last year *

$ Dollars . Cents

Monthly rent/mortgage *

$ Dollars . Cents

Financial situation *

Please help us understand why you need our assistance.

Have you applied for Care Credit? *

Yes and Denied Credit

Yes and Approved

No I have not applied

Care Credit Limit *

$ Dollars . Cents

If you have not applied or denied credit put 0.

Name of any other organization you have applied for or are working with? *

Failure to report this information will lead to disqualification of assistance

ABOUT YOUR PET'S HEALTH

Symptoms or Diagnosis: *

Date of Diagnosis *

MM / DD / YYYY

If pet has not yet been seen, please put date when symptoms began

Treatment given so far and what is the treatment plan *

Prognosis *

Pet Insurance *

Yes

No

Have Insurance but not applicable for this illness

Do you have a medical insurance policy for this pet?

Name of Vet and Clinic where pet is being seen *

If Pet has not yet been seen for symptoms please state "Not Yet Seen" If being seen by more than one vet (regular vet and specialist then list both). You must provide authorization to the clinic for Allie Care, Inc. and their volunteers to speak about your pet.

Vet/Clinic Phone Number *

### - ### - ####

Does this pet have other health issues besides the one listed above? Please provide details *

What are you seeking assistance for and how much is the estimated amount you will be needing? *

How much funds are you requesting? (As a reminder we only pay vet offices never individuals) *

Please provide an approximate dollar amount you are seeking

What amount of the bill can you pay? *

We receive numerous requests for assistance. Please tell us why you feel your pet should be considered as an Allie Cares recipient. *

File Upload: Upload any documents that you would like us to consider. These can be from your vet, a picture of your pet (we like to see them), estimates, last pay statement (attaching these now speeds up the process)

By Checking the following I agree to: *

I have contacted all vets listed in this form and provided permission for Allie Cares, Inc and their volunteers to discuss the pet listed above

I understand that completing this application does not guarantee assistance

I understand I may be required to provide additional information or documentation

I understand that all payments will be to the animal hospital or clinic and no funds will be given to an individual

I agree to assist Allie Cares, Inc with fundraising activities in the amount equal to or greater than the amount of assistance

If approved, I agree to discontinue any private raising of funds (GoFundMe...) and disclose if any other organization is helping to raise funds. Unles disclosed otherwise Allie Cares will be the only sources of funds

I understand that Allie Cares, Inc is not a vet service and only assist with providing financial assistance. The specifics of the care is between you and your vet and should be discussed with them

I understand that Allie Cares must approve any other fundraisers prior to them being active

I understand that by completing this application I am giving authorization to post my pet and any people within the picture on Allie Cares, Inc soical media, website and promotional material. Allie Cares, Inc has authorization to utilize the picture

Signature

Clear