Noah's Animal Fund Application

Noah's Animal Fund Application

Noah's Animal Fund provides financial assistance for companion animals facing a veterinary crisis. Noah's Animal Fund is a program administered by Friends of Noah - All Breed Animal Rescue
Noah’s Animal Fund provides financial assistance to qualified pet owners for payment of incurred and anticipated veterinary expenses. A program of Friends of Noah, an all-breed animal rescue, Noah’s Animal Fund’s review committee reviews each application with care, compassion, and fairness. Above all, each volunteer committee member loves and respects all animals and realizes the importance of our furry and feathered companions.

What is the Fund’s review process? Noah’sAnimal Fund review committee carefully reviews all of the applications and makes decisions based on the provided information and the expertise of the committee. Once a decision is reached, you will be notified promptly either by email or by telephone. Emergency cases will be expedited.

How are fund payments made? Payments most often go directly to your veterinary care clinic upon completion of the procedure not to exceed 90 days of acceptance. If partial payment is awarded, we ask that you arrange payment of the remainder directly with your veterinary professional.

What is required?

● To be considered for funding you must live in any of the following Wisconsin counties: Rock, Green, Jefferson, or Walworth. If you don’t live within one of these counties, please search closer to where you live for assistance.
● You must have a medical diagnosis from a veterinarian and a good long-term prognosis to be considered. Noah’s Animal Fund does not provide financial assistance for routine care (wellness visits, vaccines, spays, neuters, diagnostics, quarantines, euthanasia).
● We must have a completed application to process your request.
● The application must include all sources of income.
● The application must include the Medical Form filled out by your veterinarian.
● Noah’s Animal Fund does not cover the entire cost of any procedure. We expect you, as the pet owner, to have some financial responsibility.
● Once Noah’s Animal Fund receives the completed application, it will be reviewed. If you are approved, Noah’sAnimal Fund will contact you and your veterinarian to notify you of your approval. You will be notified if your application is denied. You will be responsible for financing whatever is not covered by Noah’s Animal Fund. This agreement will be between you and your veterinarian.
● Noah’s Animal Fund pays the approved amount directly to your veterinarian. We require the veterinarian to submit an invoice for services provided to Noah’sAnimal Fund (FON.noahsanimalfund@gmail.com). The invoice will then be submitted to the Friends of Noah Noah’s Animal Fund accountant and a check will be issued directly to the veterinarian.

I HAVE READ AND UNDERSTAND THE TERMS OF CONSIDERATION FOR FUNDING FROM NOAH'S ANIMAL FUND. BASED ON THE INFORMATION ABOVE, I BELIEVE THAT I/WE QUALIFY FOR FUNDING.
Signature

Clear
Date

MonthDayYear
Date
What kind of care do you need?

Emergency Services (0-48 hour care)Non-emergency
Please ✔ all that apply:

Financial hardshipLegal ownership of petMedical necessity (non-routine procedure)POSITIVE Short/long-term prognosis (vet verification)Validation of costs (vet verification)
APPLICANT INFORMATION
Applicant Name*

First NameLast Name
Co-Applicant (Spouse/Partner) Name

First NameLast Name
Number of Children Living in the Home*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Best Phone # to Reach You:

Area CodePhone Number
Best Email to Reach You:
example@example.com
How did you hear about Noah's Animal Fund?
PET INFORMATION
Pet's Name: *
Breed:
Age of Pet:*
Date Spayed / Neutered:

MonthDayYear
Date Spayed / Neutered*

MonthDayYear
Last Rabies Vaccine Date*

MonthDayYear
Last Distemper Vaccine Date*

MonthDayYear
Length of Ownership
Other Pets / Types:
Name of Regular Veterinary Clinic: *
Email Address of Veterinary Clinic: *
example@example.com
EMPLOYMENT INFORMATION
Applicant Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number

Area CodePhone Number
Length of Employment:*
Length of Employment:
Net (Take Home) Monthly Income*
Co-Applicant Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number

Area CodePhone Number
Length of Employment:
Net (Take Home) Income:
MONTHLY INCOME/EXPENSES:
INCOME:
EXPENSES:
PLEASE EXPLAIN YOUR NEED FOR ASSISTANCE IN THE SPACE BELOW: *
I UNDERSTAND, that it is my responsibility to pay for all charges incurred at the time services are rendered pending a decision by Noah's Animal Fund Review Committee. If funds are not disbursed within 90 days of approval, this application will become null and void. All statements within this document are true and correct to the best of my knowledge.
Pet Owner Signature (Applicant):*

Clear
Date

MonthDayYear
Date
Pet Owner Signature (Co-Applicant:

Clear
Date

MonthDayYear
Date
In order to be considered for financial assistance, you MUST have your veterinary clinic fill out the attached Medical Form. This form can also be found here on our website.

The completed form should be emailed to fon.noahsanimalfund@gmail.com.

ONLY ONCE ALL INFORMATION HAS BEEN RECEIVED CAN NOAH'S ANIMAL FUND DETERMINE ASSISTANCE.
Should be Empty:

Noah's Animal Fund Application

APPLICANT INFORMATION

PET INFORMATION

EMPLOYMENT INFORMATION