Tripawds Amputation Surgery Assistance Program
Application for reimbursement of veterinary surgery expenses. Please read complete details before applying at http://tri.pet/asap-fund
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Email *
First Time Applying? *
Today's Date: *
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Applicant (Full Name) *
NOTE: Name must match veterinarian client records.
Street Address *
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/
Pet's Name *
Pet's Age *
Pet Breed *
Reason for Amputation *
(e.g.; Cancer, Accident, etc.)
Surgery Date *
(Date of Amputation Surgery)
MM
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DD
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YYYY
Estimated Surgery Expense *
Must be verified in supporting documentation.
How will you pay for surgery? *
Select all that apply.
Required
¹Crowdfunding Source
Provide link to any/all online fundraising page(s) or social media fundraiser(s) if applicable. NOTE: If funds have been raised to cover surgery expense at time of documentation review, application will be disqualified.
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 *
NOTE: Only Include Self, Spouse and Dependent Children. (Roommates, Significant Others, and Parents Do Not Apply)
Marital Status *
Need Qualification *
How will you provide proof of 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. Proof of Enrollment can be provided in the form of current valid enrollment/membership card AND recent statement or disbursement check stubs indicating at least one month of financial assistance from state or federal agency.
OR
2. Attach proof of current annual household total income (e.g.; IRS Form 1040A, Line 15) 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. Student loan statements alone will not suffice as income verification.

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
Preferred Payment Method *
Please select preferred payment method IF you are selected as a grant recipient.
Paypal Account:
Provide Paypal account email address for prompt payment IF approved.
Mailing Address (Or Vet Contact):
Confirm mailing address for check IF approved (if different than above). Indicate "same" if same as above. If submitting payment directly to vet clinic, you must include contact name and phone number. OR: Provide primary contact at vet clinic for direct payment.
Application Authorization *
Required
Qualifying Household Income Levels
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