Peace of Mind Dog Rescue · Helping Paw Financial Assistance Application

Your Information

Name

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First Name

Last Name

Email

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Verify Email

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Email again

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Please enter the same email address again

Verify Email

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Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home phone

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Cell phone

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How many adults at this address?

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Adults' ages

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How many children at this address?

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Children's ages

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Applicant's date of birth

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(mm/dd/yyyy)

What is your preferred means of communication?

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Home phone

Cell phone

Email

Text

How did you hear about us?

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Other

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Pet's Information

Pet's name

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Type of pet

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Dog

Cat

Pet's age

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Pet's weight

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Pet's gender

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Male

Female

Breed

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If your pet is a mix, list the one or two most prominent breeds

Color

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Is this pet current on rabies and DHPP vaccines?

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Yes

No

How long have you had this pet?

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Where did you get this pet?

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Is this pet spayed/neutered?

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Yes

No

Why not?

E.g. can't afford, medical reason, didn't get around to it yet, wanted to have a litter, etc.

When did this pet last see a vet?

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Can you provide medical records?

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Yes

No

Please give name of the vet clinic and person's name the records are under

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What problem is your pet currently experiencing, or why are you applying for assistance?

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Has your pet been seen by a vet for this problem? Is there a diagnosis?

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If you have an estimate for diagnostics or treatment from your vet, how much is it ($)?

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How much can you contribute toward this estimate ($)?

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Does your pet have any other health issues that are currently being treated?

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Yes

No

Please explain

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Does POMDR have permission to speak with your veterinarian about your pet's case?

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Yes

No

Financial Information for the Household

Combined monthly income for household ($)

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Source(s) of income

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Have you applied for care credit?

Yes

No

Explanation of care credit

What other financial assistance has your pet received or have you applied for?

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Total assets ($)

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house, car, savings, stocks, etc.

Do you rent or own your home?

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Rent

Own

Other

Please explain

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Monthly rent or mortgage ($)

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Please let us know about your situation (or your pet’s) to help us make a determination about your request. Very specific information about why you are experiencing hardship right now is helpful.

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Is your hardship related to the COVID-19 crisis?

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Yes

No

Please explain

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Please upload a copy of your driver's license

Please upload a copy of your proof of income

Please upload a photo of your pet

Please upload a photo of you or a family member with your pet (optional)

Photo Release

I understand that public relations is an important part of POMDR’s ability to raise funds for people like me in need of assistance . On behalf of myself, my heirs, personal representatives, and executors, I allow POMDR to use any photographs taken of me or my pet or submitted by me for use in public relations efforts including print materials, website, and social media. Also, all photographs that I submit to POMDR will remain the property of the photographer. POMDR will have the rights to use these photographs for marketing materials or in any other ways that POMDR sees fit.

I accept the Photo Release

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Yes

No

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