Request for Financial Assistance

What services are you requesting assistance with?(Required)
Which County do you live in?(Required)

Owner's Name(Required)
Additional Owner's Name
Pet's Name(Required)
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Pet's Sex(Required)

Has your pet seen a veterinarian and received a diagnosis?(Required)
Does your pet have any of the following?(Required)
What temperament best describes your pet?(Required)
Pet Insurance(Required)
Max. file size: 128 MB.
Max. file size: 128 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)
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