Application | The Sergei Foundation

I have read and agree to our parameters for Apply for Aid" page and understand that all requirements must be met to qualify for aid: * *

Please check below when you have gone back to read the parameters, and agree to our terms for funding. *

I have read them. I agree.

Owner/Applicant Information:

How did you hear about The Sergei Foundation? *

Please be specific, if a certain vet's office, name of referral, etc.

Name *

First

Last

Address information (No PO Boxes) *

Address Line 1

City

State

Zip Code

Phone number *

Type of phone number *

Secondary phone (or re-enter number above for accuracy) *

Email (NOTE! You will be contacted at this email) *

Confirm Email

Ensure you enter the email info@sergeifoundation.org in your contacts so that our outreach does not go to SPAM. If you do not hear from us in 24 hours, check your JUNK/SPAM folders.

Your age *

Marital status *

How many children do you claim as dependents in your household? *

These are children in your home and you receive tax deductions for them (listed on your Federal 1040 form)

What is your TOTAL (Gross) household income *

Less than $23,606 a year ($1,968/month)
$26,607-$39,814 ($2,658/month)
$39,815-$40,182 ($3,349/month)
$40,183-$48,470 ($4,040/month)
$48,471-$56,758 ($4,730/month)
More than $56,758 a year

This is your income before taxes are taken out, including all jobs and money received as household income.

What type of state or federal aid do you receive? *

Food Stamps (SNAP)
SSI (disability or social security income)
Section 8 housing
Unemployment
Other
NONE

Check all that apply.

Please list what "Other" you receive from above question *

Do you currently have, or did you apply for Care Credit? (www.https://www.carecredit.com/vetmed) *

Getting credit does NOT decrease your chances of our assistance. In fact, it may aid in our amount.

How much were you awarded? *

Pet information

This section is to gather information about your sick or injured pet.

Pet's name *

What is wrong with your sick or injured pet? *

What have you paid towards this emergency so far and/or how much could you contribute? *

Pet type *

We only assist dogs or cats at this time.

Dog breed (copy) *

What type of breed? If mixed, list best guess such as Boxer/Lab mix, etc.

Weight of pet (in pounds)

Age of pet (number field only) *

Is that months or years? *

How long have you owned the pet? *

Gender *

Female
Male

Is he already neutered? *

Do you agree to neuter if we assist and he is already under anethesia? *

Is she already spayed? *

Do you agree to spay if we assist and she is already under anethesia? (copy) *

Has the pet already seen a veterinarian for this issue? *

If not and the pet is in critical pain, we require that you get to a vet asap for pain treatment; we may reimburse if you are approved. Banfield Pet Hospitals and VCA Animal Hospitals offer FREE exams (Google their name and "free exam" for details).

Name of the Veterinaian Hospital/Clinic who saw your pet for this issue *

Phone number for this veterinarian hospital *

Name of Veterinarian Hospital/Clinic who last saw your pet BEFORE this recent issue *

List name of hopsital. Put "NONE" if you have not seen a vet before.

Phone number for previous vet *

Date pet last seen by a veterinarian BEFORE this incident that you are seeking funding for:

Estimate is okay. If you have not seen a vet before, please indicate that here.

Upload Files...

If you DO NOT have the files ready to upload. You may still submit the form. Please know we will need to reach out to you by email to obtain this information, so please watch for that email or we will be unable to assist (check SPAM or JUNK folders for our email from info@sergeifoundation.org)

Upload a photo of your pet

Click or drag a file to this area to upload.

This can be current or past, we just need a photo to go with the application

Upload EITHER: 1) Current (2019) Federal 1040 Tax Form OR your SNAP Food Stamp award letter (if you receive that)

Click or drag a file to this area to upload.

Cross out social security numbers if you feel more safe doing so; we do not use that information.

If you do NOT have either of the above, upload your last full bank statement for now but more information will most likely be required upon submission.

Click or drag a file to this area to upload.

Cross out account numbers for safety; we need to see the full statement (do not screen shot balances).

Signature/Submission

Typing my full name below acts as my signature: 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: *

Date *