PACC FINANCIAL ASSISTANCE APPLICATION
If you need financial assistance for spay/neuter, please complete the following form and mail it along with any other necessary documents (W2 forms, income tax returns, etc) to: PACC, P.O. Box 1133, Franklin, VA 23851.
A PACC representative will review your application and contact you to inform you if you have been approved for financial assistance.
INSTRUCTIONS: CAREFULLY READ AND COMPLETE ALL ITEMS.
NOTE: All required financial aid forms must be received by a PACC representative 48 hours before appointments.
I. PERSONAL INFORMATION
Social Security Number _______-_____-_______
______________________________________________________________
First Name Middle Initial Last Name
If you do not have a Drivers License Number, enter NA
Drivers License Number ____________________________
Permanent Mailing Address
______________________________________
______________________________________
City State Zip Code
Home Phone Number: ( ) -
Alternate Phone Number : ( ) -
Email Address: ______________________________________
Name and Phone Number of Your Current Employer:
Name _______________________________
Phone # _____________________________
What is your annual income? ______________________
What is your annual household income? _________________________
(combined income of all household members)
II. HOUSEHOLD INFORMATION
Number of people currently living in your household (including yourself): ___________
What ages are household members?
1.________________________________________________
2.________________________________________________
3.________________________________________________
4.________________________________________________
5.________________________________________________
6.________________________________________________
7.________________________________________________
8.________________________________________________
How many vehicles does your household currently own/lease? ___________
Do you currently own or rent your home? __________
Day Care: (circle yes or no)
Do you have any children enrolled in daycare? Yes No
Do you receive financial aid services for daycare? Yes No
If you answered "Yes" to receiving financial aid services for daycare, what type: _______________________
Are you currently receiving any government financial assistance?
Yes No
If Yes, What type(s) of financial assistance are you currently receiving? (List All)
III. SPOUSE INFORMATION:
SPOUSE BACKGROUND INFORMATION:
Spouse Name ________________________________
Spouses’ Employer: ____________________________
Spouses' Address
_______________________________________________
_______________________________________________
City State Zip Code
Spouses' Phone Number: ( ) -
Pet Information:
|
Animal Type |
Number of Animals Owned |
Number of Animals Requiring Assistance |
|
Dog |
|
|
|
Cat |
|
|
Have you ever received financial assistance from PACC before? Yes No
If "Yes", What date did you receive assistance? _______________________
What animal(s) did you receive assistance for?
What type of assistance was received?
IV. CERTIFICATION
Certification:
I affirm the following statements:
I understand that in order to receive financial assistance from Partners Among Cats and Canines, I must honestly complete the application. I must provide a copy of mine and my spouses’ Tax Return Form. If I fail to provide a copy of the required forms and my completed Financial Aid Application
48 hours before my animal(s) appointment I may be denied financial aid and/or services.
I understand that I may be subject to a home inspection by a PACC representative before financial assistance is granted, I therefore agree to allow a PACC representative to complete a home visit upon request.
3. I certify that I am the legal owner of all animals in which I am asking financial assistance.
I certify that all information given in this application is true and correct, and that I read and understand all items set for in this Financial Aid Application.
Date: ___________________________________________
Name of Applicant (Print) : ______________________________
Signiture of Applicant:_____________________________________
WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION ON THIS FORM (OR RELATED DOCUMENTS) SHALL BE SUBJECT TO A FINE OF NOT MORE THAN $10,000 OR TO IMPRISONMENT OF NOT MORE THAN FIVE YEARS, OR BOTH, UNDER PROVISIONS OF THE UNITED STATES CRIMINAL CODE.
