Form Builder

Please tell us how you heard about us:

Name

Address

City

State

Zipcode

Home phone

Cell phone

Email address

Employer name

Spouse/partner name

Gross monthly household income

Please describe source of income (employment, social security, disability, etc.)

Upload Proof of Financial Hardship

Please upload document(s) showing proof of financial hardship. Some examples of documents that can prove financial hardship are recent pay stubs, unemployment or disability benefit statements, SNAP/CalFresh letters or EBT card, Medi-Cal/Medicaid letters, etc.

Pet's name

Breed

Pet type

Cat
Dog
Other

Pet's sex

Male
Female

Pet's age

Pet's approximate weight

Vet name you'd like to use

Vet phone number you'd like to use

List all veterinarians that your pet has seen

Please describe your pet's condition and how it happened

Has your pet received any treatment for this condition? If yes, please describe

What is the estimate for treatment?

How much can you afford to pay toward your pet's treatment?

Have you contacted other organizations for financial help? If yes, which ones?

Have you received any pledges toward your pet's treatment? If yes, how much?

Have you applied for Care Credit? If yes, were you approved and for how much?

If you have not applied for Care Credit we suggest that you do so. This credit card allows no interest for 6-12 months. Visit www.carecredit.com or call 800-677-0718 to apply for a Care Credit card.

We may need your permission to acquire x-rays and the vet's notes to help find the most reasonably priced treatment for your pet. If necessary, will you contact your vet and give us permisison to receive your pet's records?

I understand that veterinary treatments or spay/neuter surgery has the risk of complications, including death, to my animal. I hereby assume full responsibility for any risk of sickness, injury or death of my animal due to my voluntary participation in the Animal Assistance Program.

By accepting financial or food assistance from AALOC you agree to allow us to use all or part of your story (without disclosing your name) and pictures of your pet in our newsletter, on our website, Facebook, etc.

I declare under penalty of perjury, that the information provided above is true and correct to the best of my knowledge and I give AALOC permission to verify any information provided by including my signature below.

Signature

Date