Tripawds Gear Fund Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Three Legged Dog Assistive Device Donation Program
NOTE: Three applications will be accepted on a first-come, first-served basis each month. Please read complete details before applying at http://tri.pet/gearfund

Email *

First Time Applying? *

Yes, This is my first application.

I have applied once before.

Original Application Date:

(Or Today's Date)

YYYY

Applicant (Full Name) *

NOTE: Name must match supporting documentation submitted

Shipping: Delivery Address *

Provide complete street address, U.S. only, no P.O. boxes.

Shipping: City, State & Zip Code *

Telephone *

Email Address *

Tripawds Username *

Tripawds community participation is encouraged to get and share the best amputation recovery and care tips. Register at http://tripawds.com/start/

Dog's Name *

Flagline Sizing: Girth Measurement

Ruffwear Harness Size *

Only applicable if Flagline harness is selected above. Refer to sizing chart below. Take the girth measurement carefully while your dog is standing up. Please measure carefully, there are no returns or exchanges.

L/XL

MED

XXS

Color may be substituted based on availability.

Preferred Color

Sage Green

Blue Dusk

Salmon Pink

Alpenglow Pink

Basalt Grey

Lichen Green

Clear selection

INCOME REPORTING

NOTE: Annual gross household income disclosure required in addition to Need Qualification documentation.

Household Income *

Total annual income of all people in household.

Number of People in Household *

Need Qualification *

How will you provide proof of qualification?

Entitlement Program Enrollment Proof

Documented Income

QUALIFICATION NOTES:

1. Email proof of enrollment in state or federal entitlement program, including: WIC, welfare, food stamps, Medicaid, VA Disability Compensation, Social Security Disability or Supplemental Security Income.
OR
2. Email proof of current annual household income at or below 200% of federal or state poverty guidelines. See Table 1 below for details. Proof of income can be provided in the form of: a) current pay stub(s) indicating at least six months of income, or b) your most recent income tax forms. All documentation must show the same name(s) as indicated on the vet clinic receipt for amputation surgery.

NOTE: We do not need your social security number. Please omit from all documents.

PLEASE REFER TO CURRENT FEDERAL POVERTY GUIDELINES FOR GROSS ANNUAL INCOME BELOW. 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA. FOR FEDERAL POVERTY GUIDELINES IN ALASKA AND HAWAII, PLEASE VISIT https://aspe.hhs.gov/poverty-guidelines

APPLICATION CHECKLIST

I AGREE to provide a photo of my dog wearing the harness along and brief article for publication by Tripawds if selected as a grant recipient.

INCLUDE: Copy of photo ID

INCLUDE: Financial Need Documentation...

1. Proof of entitlement program enrollment (award letter or payment stub), OR:

2. Proof of income (Paycheck stubs indicating at least 6 months of income or most recent Tax forms)

EMAIL ALL SUPPORTING DOCUMENTATION IN ONE EMAIL TO FOUNDATION@TRIPAWDS.ORG WITH THE SUBJECT "GEAR FUND APPLICATION"

Qualifying Household Income

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms