Tripawds Amputation Surgery Assistance Program
Application for reimbursement of veterinary surgery expenses. Please read complete details before applying at http://tri.pet/asap-fund
First Time Applying? *
Original Application Date:
(If Applicable)
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Applicant (Full Name) *
NOTE: Name must match veterinarian client records.
Your answer
Street Address *
Your answer
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
Pet's Name *
Your answer
Pet's Age *
Your answer
Pet Breed *
Reason for Amputation *
(e.g.; Cancer, Accident, etc.)
Your answer
Surgery Date *
(Date of Amputation Surgery)
MM
/
DD
/
YYYY
Estimated Surgery Expense *
Must be verified in supporting documentation.
Your answer
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 profile(s) if applicable.
Your answer
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.
Your answer
Number of People in Household *
NOTE: Only Include Self, Spouse and Dependent Children. (Roommates, Significant Others, and Parents Do Not Apply)
Your answer
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 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
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.
Your answer
Mailing Address:
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.
Your answer
Application Authorization *
Required
Qualifying Household Income Levels
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