Rochester Hope for Pets Application for Financial Assistance

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If you need help completing this form, please call 585-532-7406, or email info@rochesterhopeforpets.org.

Email *

Applicant Name *

Phone Number *

Address *

City *

Zip Code *

Number of Adults in Household *

Number of Children in Household *

Number of Pets in Household *

Total Family Income (per year) *

Applicant's Age (in years) *

Please indicate if you are a recipient of any of the following: *

New York State Temporary Assistance

Social Security Disability Insurance (SSDI)

Social Security Income (SSI)

Social Security Benefits

Supplemental Nutritional Assistance Program (SNAP, formerly known as Food Stamps)

Medicaid

Unemployment Benefits

Home Energy Assistance Program (HEAP)

Military Service Member or Veteran

Fall below 2019 HUD Income Guidelines (see https://tinyurl.com/2k4y22ft for more details)

None of the above

Required

Pet Name *

Pet Species *

Dog

Cat

Other:

Pet's Breed *

Pet's Age (in months or years) *

Pet's Sex *

Female

Male

Spayed/Neutered? *

Yes

Do you own the animal? *

Yes

How and when did you acquire the animal? *

If your pet is a rescue, where did you rescue them from? *

Which veterinarian does your pet regularly see? If none, leave blank.

Type of Service Required *

Please describe the nature of care your pet requires and any qualifying life event that has affected your ability to cover the full cost of care. *

Please send an estimate from your veterinarian regarding the cost of your pet’s care. This is required for your application to be considered. You may email, fax, or mail it. *

Emailed to info@rochesterhopeforpets.org

Mailed to Rochester Hope for Pets, 2816 Monroe Avenue, Rochester, NY 14618

Total Anticipated Fee *

From which veterinary hospital did you obtain the estimate? *

By submitting this application, I attest that I have accurately completed this application and understand Rochester Hope for Pets has the right to accept or reject this application without recourse or reason. I understand that funds may not be available at the time of application. I also understand that I will be contacted if an award is to be granted. I further certify that the information given above is true.

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