Tripawds Gear Fund Application
Three Legged Dog Support Harness Donation Program
NOTE: Application deadline is the 1st and 15th of each month. You may apply a maximum of two times.
First Time Applying?
Original Application Date:
(If Applicable)
MM
/
DD
/
YYYY
Applicant (Full Name)
NOTE: Name must match supporting documentation submitted
Your answer
Shipping: Delivery Address
Your answer
Shipping: City, State & Zip Code
Your answer
Telephone
Your answer
Email Address
Your answer
Tripawds Username
Tripawds community participation is encouraged to get and share the best amputation recovery and care tips. Register at http://tripawds.com/start/
Your answer
Dog's Name
Your answer
Ruffwear Webmaster Harness Sizing
Take the girth measurement carefully while your dog is standing up. Please measure carefully, there are no returns or exchanges.
Available
Harness Size
See sizing chart above. Please measure carefully. There are no returns or exchanges.
Your answer
Preferred Color
NOTE: Color may be substituted based on availability.
INCOME REPORTING
NOTE: Annual household income disclosure required in addition to Need Qualification documentation.
Household Income
Total annual income of all people in household.
Your answer
Number of People in Household
Your answer
Need Qualification
QUALIFICATION NOTES:
1. Attach 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. Attach 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.

APPLICATION CHECKLIST
Qualifying Household Income
Submit
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