Grant Application Form

DID YOU READ OUR GRANT PARAMETERS TO SEE IF YOU QUALIFY?  Review them here  BEFORE YOU FILL OUT THE FORM or your application may not be reviewed.  Also, please have your documents ready to attach for income verification for quickest review/approval.  This can be either your most recent year's federal 1040 tax form OR both a state/federal disability award letter and last month's complete bank statement.  There is a place at the end to upload files - it must be in .pdf or .jpg format (we will accept a photo of the form attached as a .jpg file).  For your safety, CROSS OFF social security numbers as we do not need that information.  You may choose to fax it to us at 336-306-8783, but please put in your application notes that you are faxing it separately.

Ready to proceed? Please complete the form below and click "Submit." Required fields are marked with a small, red asterisk (*). After you submit, you will see a page that confirms your application that looks like this.  If you do not see this, it has not been submitted. The page you are redirected to is our resources page that lists other possible sick and injured animal funds that you may wish to investigate/apply.

application submitted page graphic_small web

 

I have read and understand the terms and conditions on the "Apply for Aid" page and understand that all requirements must be met to qualify for aid: *
Owner's Name: (required) *
Address: (required) *
Primary Phone: (required) *
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Alternate Phone:
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E-mail Address: (required) *
Re-enter E-mail Address: (required) *
Your Age: (required) *
How did you hear about the Sergei Foundation? *
Marital Status: (required) *
TOTAL YEARLY HOUSEHOLD INCOME, line 22 on your federal 1040 tax form: (required) *
How many children live with you that you claim on your taxes? (required) *
Are you currently on State or Federal aid? (required) *
If yes, list type of aid received:

Family Pet Information (All Info Required)

Your Pet's Name: *
Type of Animal: *
Breed (ex: husky, poodle, manx cat, etc.) *
Pet's Age.
Is age you listed in "years" or "months?" *
Pet's Weight: *
Gender: *
Spayed/Neutered: *
How long has the animal been in your care? *

Vet Information (All Info Required)

Has your pet been seen by a veterinarian for this specific injury or illness? *
If Yes, please provide the name and phone number of the veterinarian seen:
Date of your last vet exam PRIOR to this injury/illness? (required) *
Name and phone number of the veterinarian(s) seen for routine exams and vaccinations where we can call to verify pet history over the past 1-3 years: *
Have you applied for any Care Credit or financial assistance from your vet within the last 30 days? (required) *
How much were you awarded? (required)
Fully explain the problem with your pet, providing background on how the injury or illness occurred and why you are asking for grant assistance. List any quote/estimate information you may have already received from a vet with dates funding is needed and how much you are able to pay towards that estimate: *
This is not required for funding, but would you be willing to give back to The Sergei Foundation through volunteering at an event or assisting with a fundraiser or fundraising efforts?
I attest that the above information is true and correct and that The Sergei Foundation may contact our veterinarian(s) provided. If funds are granted, I understand that they will be given directly to the veterinarian who will perform the services on our pet. In addition, I grant permission to The Sergei Foundation to use information, photos and videos of our pet for promotional purposes, including but not limited to our website and public relations efforts: *
Signature (please type your full name:) *
Today's Date: *

Upload Your Files Below.  If you do not attach it here, it will slow down our review as you will get an email stating we need this in order to continue.   **Max file size for each is 2mb**

We need EITHER

1) Your Federal 1040 Tax Form (NOT your W2, but the 1040 form)

OR

2) Your Federal/State aid award eligibility letter AND your last month's bank statement. 

Upload your 2016 FEDERAL 1040 TAX FORM: (If you have this, it is the only file needed at this time other than a photo of your pet.)
OR... If you don't upload your tax form, upload your state/federal aid AWARD LETTER.
AND we need your last month's bank statement if you upload any award letter other than SNAP/Food stamp letter.
Upload a PHOTO of your pet:
Upload additional info (optional):
Word Verification: