C.A.Re Fund Application Companion Animal Relief Application Name* First Middle Last Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Secondary PhoneEmail Address* Photo ID*Max. file size: 256 MB.*A copy of your photo ID is required upon submission of this application. If your photo ID does not reflect your current address, please provide a copy of a utility bill showing your name and the correct address.How many people are in your household?* Have you ever received C.A.Re Fund Assistance?* Yes No If yes, when? (If not applicable, respond with N/A)* Have you applied for Care Credit?* Yes No Have you applied for Scratchpay?* Yes No Pet InformationHow many dogs do you have?* How many cats do you have?* Please provide the following information ONLY for your pet(s) that needs our services:*Name of PetSexAgeUp to Date on Rabies Vaccine?Approximate WeightCat or Dog Please give a brief description of your pet(s)'s medical needs:*Has the pet(s) in need of veterinary care ever had vaccines or other veterinary treatment?* Yes No If yes, name of Veterinarian (If not applicable, enter N/A)* City/State (If not applicable, enter N/A)* City State / Province / Region Household IncomeAre you participating in The Food Stamp Program, Medicaid, TANF, or SSI?* Yes No Applicant's Employer* Gross Monthly Income*Spouse's Employer (If not applicable, respond with N/A)* Spouse's Gross Monthly Income (If not applicable, respond with N/A)*Any other monthly income or assistance (Disability, child support, alimony, etc. If not applicable, enter N/A)*Verification of Income*Max. file size: 256 MB.*A verification of your household's income is required upon submission of this application.Please note: The Roanoke Valley SPCA may offer only a portion of the total amount of your bill, depending on the amount of aid funds available in the C.A.Re Fund and the amount of the veterinary services required. The maximum amount of funding offered through this fund will not exceed $400.00 and will be paid directly to the veterinary clinic offering the service. You are responsible for a minimum of 10% of the overall bill. The amount you are responsible for over and above the C.A.Re Fund assistance will need to be arranged for with the veterinary office.Required: It is state law that your pet's rabies vaccination be current or updated at the time of receiving services. The Roanoke Valley SPCA C.A.Re Fund assistance may or may not include the cost of a rabies vaccine, depending on the amount awarded.I HEREBY GIVE THE ROANOKE VALLEY SPCA CONSENT TO COMMUNICATE WITH ANY OTHER PERSONS OR PARTIES CONCERNING MY HISTORY FOR THE PURPOSE OF VERIFYING THE INFORMATION ON MY APPLICATION. I CERTIFY THAT THE ABOVE NAMED ANIMALS ARE OWNED BY ME PERSONALLY. IF APPROVED, I WILL BE NOTIFIED OF THE AWARD AND THE ROANOKE VALLEY SPCA WILL WORK DIRECTLY WITH THE VETERINARY CLINIC TO DISCUSS PLAN OF TREATMENT AND MAKE PAYMENT ARRANGEMENTS FOR THE AMOUNT OF THE AWARD. I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR PAYMENT OF ANY AMOUNT DUE TO THE VETERINARY CLINIC OVER AND ABOVE THE CARE FUND ASSISTANCE.Date* MM slash DD slash YYYY Applicant Signature* Reset signature Signature locked. Reset to sign again