EMMA'S FOUNDATION FOR CANINE CANCER, INC
Application for Assistance

Emma's Foundation for Canine Cancer raises funds for dogs who due to the owner's/caretaker's financial constraints, would not be able to have or complete cancer treatment without assistance.
Assistance is based on proven financial need.

TO APPLY:

1. Alert your veterinarian that someone from Emma's Foundation might call him/her. Give your permission to freely discuss with us all aspects of your dogs case. Veterinarians treating EFFCC dogs are encouraged to provide a discount. We will establish this with your doctor after we review your application. If your doctor will not discount fees, but you wish to receive financial assistance we may try to refer you to a doctor nearby who will.

2. Provide financial info BEFORE you submit the application below:
* We will not review your application unless we have received the first page of your most recent tax return. Before you complete and submit the form below, mail us the first page of your most recently filed tax return. Make a copy of the page, cross out your social security number and mail this info to:
Emma's Foundation, PO Box 1115, Milton, VT 05468-1115
or scan and email to
- If you are married filing separately, send the first page of both (yours and your spouses).
- Send other financial records to us to help us prove that you are in need of assistance.
Send only 1 or 2 documents other than your tax return. Examples: foreclosure notice, unemployment check stubs/statements, bankruptcy documents, etc, EFFCC helps those most in need.

3. Fill in and SUBMIT the form below. After we receive your financial info (#2 above), we will review your application, contact you veterinarian and then contact you. If we do not have the funds or cannot raise funds for your dog's treatment, we will email or send a letter to you with that news. If we can, you will receive an email or letter with an offer. We will also ask that you assist with fundraising for your dog's treatment and ask that you keep EFFCC abreast of this process.
Until you receive the offer email or letter, we have not agreed to provide funding.
* We will not review your application until we receive your tax return.

About You

Date

Name

Address

DOB

Email address

Phone/Cell

Are you currently employed?  Yes   No

*If no, mail unemployment letter to
Emma's Foundation, PO Box 1115 Milton, VT 05468-1115

Title at most recent job    Employers phone

Spouse Name    Spouse occupation

Household income

Projected household income (current year) (last tax year)

Assets (checking account)    Assets savings accts (include pensions)

Do you receive social services? (which and how much?)

Names/Ages of anyone you claim as a dependent:

Do you own your own home? Yes   No

ABOUT YOUR DOG

Name Breed DOB Weight

Dogs gender  Male   Female

Is your dog spayed/neutered?   Yes   No

If not spayed/neutered, why not?

If you have pet insurance, provide name and company and policy number

Type of cancer (if tumor, also say location)

Date diagnosed

Treatment given up to now

Treatment recommended

Your veterinarians treatment cost (if given)

Most recent vaccinations (name of vaccine given and date given)

*Please do not give vaccinations to a dog with cancer! If your dog is due for rabies, we will provide a waiver form.

Any other health issues your dog has had (include past cancers)

List any other organizations to which you have applied for help.
(Include: Name of organization, phone number, website address, name of person you spoke to, response to your request. Did they provide any funding, how much?)

Have you applied for assistance to pay for your dog's treatment from Care Credit?   Yes   No

If yes what was their response?

Names/ Ages of other pets in your home

YOUR VETERINAIAN CURRENTLY PROVIDING TREATMENT

Vet name Clinic

Phone/Fax

Address

Have you given your vet permission to speak with Emma's Foundation about your dog? Yes  No

* If we call your clinic and they have not received your permission, your application will be denied.

Briefly, what is your financial situation? Why do you need assistance? What will you do if Emma's Foundation cannot help? (limit to 100 words)

What amount are you able to pay towards your dogs cancer treatment?

If your dog needs surgery, type in the amount that you can get together in the next 2 weeks.

If your dog needs chemo, type in the amount you can contribute each week.

Emma's Foundation recipients are required to contribute as much as they can toward treatment., and to also help with fundraising. Start now putting aside any funds you can apply towards treatment.

Describe what makes your dog special. How will you feel if you find out his treatment or part of his treatment will be funded? (limit to 100 words)

 

Attach an image of your dog:

To submit this form, please enter the characters you see in the image below:

Home | Donate | Ways You Can Help | Canine Cancer Info / News | Rainbow Bridge & Stories Shared | Upcoming Fundraisers | Shop Products | Resources | Our Supporters | Emma's Angels, Past & Present | Meet the Board | Memorial Wall | Contact Us

© Copyright 2017 Emmas Foundation
Tampa Web Design & hosting by Off the Page Creations