Sam's Hope Veterinary Care Assistance Application
You MUST be a resident of Southeastern Pennsylvania and meet at least one of the following requirements to
qualify for assistance.
 You qualify as low income, see chart below on website.
 You are unemployed.
 You are receiving government assistance.
 You are disabled and on a fixed income.
 You are a senior citizen on a fixed income.
 You are homeless.

Applicant MUST provide:
Proof of identification, (driver's license, or other photo identification with name and address)
Recent proof of income, (check stub, tax return, W-2, 1099)
Proof of qualifying benefits, (Medicaid, Unemployment, Food Stamps, SSI)
Diagnosis, prognosis and treatment plan from veterinarian
Care Credit denial / approval
Six photos; pet alone and with family
Veterinarian's name, address, and phone number
Completed grant application

PLEASE EMAIL ALL DOCUMENTATION, PHOTOS, ETC. TO: samshope.org@gmail.com

Email address *
Date *
MM
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DD
/
YYYY
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Cell Phone *
Your answer
Name of Pet *
Your answer
Type of Pet *
Age of Pet *
Your answer
Breed *
Your answer
Spayed/Neutered? *
Description of Pet's Illness, Injury, Diagnosis, etc. *
Your answer
Is Medical Treatment Urgent? *
Estimated Cost of Treatment *
Your answer
Are You Willing to Contribute 10% of Cost of Treatment? *
Is Follow Up Care Required? *
Are You Willing to Contribute 10% of the Cost of Follow-Up Care? *
Are You Willing to Bring Your Pet to Our Veterinary Partners for Treatment? *
Veterinarian's Name *
Your answer
Veterinarian's Address *
Your answer
Veterinarian's City *
Your answer
Veterinarian's State *
Your answer
Veterinarian's Zip Code *
Your answer
Veterinarian's Phone Number *
Your answer
Veterinarian's Email Address *
Your answer
Please Describe Your Financial Hardship in Detail *
Your answer
SIGNATURE - By signing this application, you attest that: All information provided is true, complete and correct. You have reviewed the eligibility requirements for veterinary care grants, and meet the qualifications. You understand that the grant will be paid directly to the treating veterinarian. You agree to pay 10% of treatment and follow up care, and for the remainder of medical costs not covered by the grant. You agree that Sam's Hope is not liable for the outcome of any medical diagnosis, treatment, etc. You consent to allow Sam's Hope to use pictures, medical information for the purposes of fundraising and promotion. Your application is NOT complete until we receive evidence of financial hardship. *
Your answer
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