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.
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