Partners Among Cats and Canines

 
 

Financial Aid Application

PACC FINANCIAL ASSISTANCE APPLICATION

If you need financial assistance for spay/neuter, please complete the following form and mail it along with any other necessary documents (W2 forms, income tax returns, etc) to: PACC, P.O. Box 1133, Franklin, VA 23851.  

A PACC representative will review your application and contact you to inform you if you have been approved for financial assistance.

INSTRUCTIONS: CAREFULLY READ AND COMPLETE ALL ITEMS.

NOTE: All required financial aid forms must be received by a PACC representative 48 hours before appointments.

I. PERSONAL INFORMATION

Social Security Number _______-_____-_______

______________________________________________________________

First Name Middle Initial Last Name

If you do not have a Drivers License Number, enter NA

Drivers License Number ____________________________

Permanent Mailing Address

______________________________________

______________________________________

City State Zip Code

Home Phone Number: ( ) -

Alternate Phone Number : ( ) -

Email Address: ______________________________________

 

Name and Phone Number of Your Current Employer:

Name _______________________________

Phone # _____________________________

What is your annual income? ______________________

What is your annual household income? _________________________

(combined income of all household members)

 

II. HOUSEHOLD INFORMATION

Number of people currently living in your household (including yourself): ___________

What ages are household members?

1.________________________________________________

2.________________________________________________

3.________________________________________________

4.________________________________________________

5.________________________________________________

6.________________________________________________

7.________________________________________________

8.________________________________________________

How many vehicles does your household currently own/lease? ___________

Do you currently own or rent your home? __________

Day Care: (circle yes or no)

Do you have any children enrolled in daycare? Yes No

Do you receive financial aid services for daycare? Yes No

If you answered "Yes" to receiving financial aid services for daycare, what type: _______________________

Are you currently receiving any government financial assistance?

Yes No

If Yes, What type(s) of financial assistance are you currently receiving? (List All)

 

III. SPOUSE INFORMATION:

SPOUSE BACKGROUND INFORMATION:

Spouse Name ________________________________

Spousesí Employer: ____________________________

Spouses' Address

_______________________________________________

_______________________________________________

City State Zip Code

Spouses' Phone Number: ( ) -

Pet Information:

Animal Type

Number of Animals Owned

Number of Animals Requiring Assistance

Dog

Cat

 

 

Have you ever received financial assistance from PACC before? Yes No

If "Yes", What date did you receive assistance? _______________________

What animal(s) did you receive assistance for?

 

 

What type of assistance was received?

 

IV. CERTIFICATION

Certification:

I affirm the following statements:

I understand that in order to receive financial assistance from Partners Among Cats and Canines, I must honestly complete the application. I must provide a copy of mine and my spousesí Tax Return Form. If I fail to provide a copy of the required forms and my completed Financial Aid Application

48 hours before my animal(s) appointment I may be denied financial aid and/or services.

I understand that I may be subject to a home inspection by a PACC representative before financial assistance is granted, I therefore agree to allow a PACC representative to complete a home visit upon request.

3. I certify that I am the legal owner of all animals in which I am asking financial assistance.

I certify that all information given in this application is true and correct, and that I read and understand all items set for in this Financial Aid Application.

 

Date: ___________________________________________

Name of Applicant (Print) : ______________________________

Signiture of Applicant:_____________________________________

 

 

WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION ON THIS FORM (OR RELATED DOCUMENTS) SHALL BE SUBJECT TO A FINE OF NOT MORE THAN $10,000 OR TO IMPRISONMENT OF NOT MORE THAN FIVE YEARS, OR BOTH, UNDER PROVISIONS OF THE UNITED STATES CRIMINAL CODE.

 

 

 

 
 
   

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