Sam's Hope Pet Food 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.

The following information MUST accompany application:
Recent proof of income, (check stub, tax return, W‐2, 1099).
 Proof of qualifying benefits, (Medicaid, Unemployment, Food Stamps, SSI).
 Proof of identification, (driver's license, or other photo identification with name and address).
 Completed pet food assistance application.

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

Email address *
Date *
MM
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DD
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YYYY
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Cell Phone *
Your answer
How many cats do you own? *
Your answer
How many cats are not spayed/neutered? *
Your answer
How many dogs do you own? *
Your answer
How many dogs are not spayed/neutered? *
Your answer
Breed and weight of each dog? *
Your answer
SIGNATURE - By signing this application, you attest that all information provided is true, complete and correct and that you have reviewed the eligibility requirements for pet food assistance and meet the qualification. Your application is not complete until we receive evidence of financial hardship. *
Your answer
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