Judith Goins Behavior Support Fund Application

Name*

First Middle Last

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone*

Secondary Phone

Email 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.

Have you ever received financial assistance from the Roanoke Valley SPCA in the past?*

Yes
No

If yes, when? (If not applicable, respond with N/A)*

Pet Information

How 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 Pet	Sex	Age	Up to Date on Rabies Vaccine?	Approximate Weight	Cat or Dog

Please give a brief description of your pet(s)'s behavior issues for which you would like training support:*

Are the pet(s) in need of behavior support spay or neutered (fixed)?*

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 Income

Are 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.

The Roanoke Valley SPCA is committed to positive reinforcement and fear free training methods. Trainers must be approved by the Roanoke Valley SPCA Veterinarian.

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 Judith Goins Behavior Assistance Fund and your household income based on the Federal Poverty Guidelines . The maximum amount of funding offered through this fund will not exceed $500.00 and will be paid directly to the approved training partner 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 Judith Goins Behavior Assistance Fund will need to be arranged for with the approved behavior partner.

Required: It is state law that your pet's rabies vaccination be current or updated at the time of receiving services

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 TRAINING PARTNER 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 APPROVED TRAINER OVER AND ABOVE THE JUDITH GOINS BEHAVIOR ASSISTANCE FUND ASSISTANCE.

Date*

Applicant Signature*

Judith Goins Behavior Support Fund Application