Request for Financial Assistance What services are you requesting assistance with?(Required) In-Home Euthanasia Individual Cremation (ashes back in an urn) Communal Cremation (ashes spread at sea) Which County do you live in?(Required) San Diego Riverside Other Owner's Name(Required) First Last Additional Owner's Name First Last Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Current Employer (if working)(Required)Work Phone(Required)Pet's Name(Required) First Pet's Date of Birth(Required) MM slash DD slash YYYY Pet's Sex(Required) Male Female Spayed/Neutered?(Required) Yes No Pet's Weight(Required)Species(Required) Dog Cat Other Breed(Required)Has your pet seen a veterinarian and received a diagnosis?(Required) Yes No Pet's Medical Condition/Reason for Euthanasia(Required)Current Veterinary Hospital(Required)Speciality HospitalDoes your pet have any of the following?(Required) Pale or discolored gums Labored breathing Collapse Multiple seizures Liver, spleen, heart or lung tumor/ Mass or tumor in the Abdomen/Belly Fluid around heart Not eating/Has not gotten up in several hours or days History congestive heart failure and faster or harder breathing Breaths more than 50 per minute Panting (cat only) What temperament best describes your pet?(Required) Docile Loves everyone Wary of new people Scared of people Protective Growly in pain Nippy in pain Reactive toward new people Aggressive tendencies Has bitten/nipped before Ownership Duration(Required)Pet Insurance(Required) Yes No Number of Adults in Household(Required)Annual Household Income, including all adults(Required)Number of Children in Household(Required)Monthly Rent/Mortgage(Required)How much have you spent on your pet in the last 60 days?(Required)How much can you pay for your pet's treatment today?(Required)Nature of financial hardship (please be specific)(Required)Financial Assistance (if currently receiving any)(Required)Care Credit Results (Submit Care Credit results from all adults in the home - apply at www.carecredit.com)(Required)Max. file size: 500 MB. Proof of financial hardship for all adults in the household (Screenshot or documentation of CURRENT available balances -your balances as of today) for both checking and savings accounts (if applicable), OR 1-month of current bank transactions (most recent, if applicable), OR, IF pet owner(s) do not have bank accounts, other acceptable forms of income include: 1040 tax form, Social Security Income, Food stamps, Unemployment or government assistance paperwork (if applicable)(Required)Max. file size: 500 MB. Signature (I declare that I have exhausted all alternative options available to me for financial assistance, however, I agree to reimburse Paws into Grace for any funds received upon a change in my financial circumstances. In addition, I hereby assign to Paws into Grace all rights to any amounts received from insurance or other source of recovery related to this matter. I hereby waive any and all claims for liability against Paws into Grace, and understand that Paws into Grace hereby reserves the right to deny a Request for Financial Assistance to anyone for any reason. I understand that if I am approved for funding, I am not automatically approved for any further assistance. I authorize Paws into Grace to use my and/or my pet’s photograph and any information relating to the payment of funds pursuant to this application for any purpose. declare, under penalty of perjury, that the foregoing is true and correct to the best of my knowledge.)(Required) Checking this box acts as my digital signatureDate(Required) MM slash DD slash YYYY
