Financial Wavier
Please fill this form out completely. Email required documentation at the email below. Please note, we CAN NOT approve incomplete applications or applications without proper documentation.
Email address *
Name *
Address *
Phone *
Email *
Household Members (age, gender, relationship) *
Financial Assistance *
Disability *
Food Stamps *
Social Security *
Social Security Disability *
Unemployment *
Worker's Compensation *
Total monthly gross income (including all members of the household) *
Program you are requesting assistance for *
Did you submit a copy of your financial assistance income and proof of residence to *
I understand that if ALL documentation is not submitted to HALO within 7 days, that my request will not be considered *
I certify that all of the above information is true accurate (type name) *
Please type your name below *
I agree that by typing my name above this is a legal digital signature *
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This form was created inside of Helping Animals Lost and Orphaned-HALO.