Assistance Request Form

Please fill out the form below so we can better understand your needs and determine how we may be able to help.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

What county do you reside in? *

Are you currently employed? *

• Yes
• No

Do you currently receive any government or state assistance? *

• Food Stamps (SNAP)
• Disability (SSI or SDI)
• Unemployment Benefits
• Workers Compensation
• Housing Assistance / Section 8
• Temporary Assistance For Needy Families (TANF)
• Other (explain in additional information section below)
• None

Estimated monthly household income *

Household size (adults and children) *

Please provide a brief description of your financial hardship that is making it hard to pay for your pets vet care. *

Vet information (Business name, phone number, and address) *

Does your vet have an estimate prepared? (If yes, please send a copy of estimate to team@theinfinityprojectnfp.org) *

• Yes
• No

Pet Information (Species, Name, Age, Gender, Breed, Weight) *

Do you currently own this pet? *--- Select Choice ---YesNo, I recently found this pet (explain below)

us phone medical

What medical issue is your pet currently experiencing? *

When did the issue begin? *

Has your pet already been seen by their vet? *

• Yes
• No

How much are you personally able to contribute towards your pets care? *

How much assistance are you requesting from The Infinity Project NFP? *

What steps have you taken so far to obtain funding for your pets medical care? *

• CareCredit Application
• Scratchpay Application
• Payment plan with vet
• Borrowing from family
• Personal fundrasing (GoFundMe, local Facebook groups, ect)
• Applying to other nonprofits
• Other (explain in additional information section below)
• The Infinity Project NFP is the only step I have taken so far

Have you received assistance from us before? *--- Select Choice ---YesNo

Additional information or questions:

By submitting this form, I acknowledge that I may be contacted for more information and proof of hardship. *

• I Acknowledge

By submitting this form, I acknowledge that the assistance provided is subject to eligibility and funding availability. *

• I Acknowledge

By submitting this form, I authorize The Infinity Project to contact my veterinarian and verify information. *

• I authorize

Submit