802.598.1263 | 802.598.3462 emmasfoundation@yahoo.com

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.

Please note that Emma’s Foundation is ONLY able to help New England and Florida Residents at this time.

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 emmasfoundation@yahoo.com
– 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

* = required fields

Are you currently employed?* YesNo - If no, please mail unemployment letter to: Emma's Foundation, PO Box 1115 Milton, VT 05468-1115

Do you own your own home?* YesNo

About Your Dog

Dogs Gender* MaleFemale

Is your dog spayed/neutered?* YesNo

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

Have you applied for assistance to pay for your dog's treatment from Care Credit?* YesNo

Your Veterinarian Currently Providing Treatment

Have you given your vet permission to speak with Emma's Foundation about your dog?* YesNo

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

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.