Emergency Vet Bill Assistance Application

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Supporting Families & Pets In Southern Illinois

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Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

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? *

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

own received The

Have you received assistance from us before? *

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

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