Mildred E. Smernoff Fund

The Mildred E. Smernoff Animal Care Fund was established in December 2006 for the care and treatment of animals for needy and low-income individuals in Southwest Riverside County.

Please fill out the following fields to the best of your ability and as accurately as possible.
Client Name*
Age*
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone*
Email*
example@example.com
# of people in household*
Current Annual Income*
Sources of Income (Click all that apply)*

SSIPensionEmploymentSocial SecurityOther
List your total number of pets:
Cats
Total Number
Dogs
Total Number
Other (please specify)
Total Number
Which pet(s) currently need veterinary care?

(Breed / Name of Pet / Sex / Age / Care Needed or Requested)
Pet 1
Breed/Type of Pet*
Please specify breed/type of pet (Pug, Chihuahua, Cat, Bunny, etc.)
Name of Pet*
Sex*
Age*
Care Needed or Requested*
Pet 2
Breed/Type of Pet
Please specify breed/type of pet (Pug, Chihuahua, Cat, Bunny, etc.)
Name of Pet
Sex
Age
Care Needed or Requested
Pet 3
Breed/Type of Pet
Please specify breed/type of pet (Pug, Chihuahua, Cat, Bunny, etc.)
Name of Pet
Sex
Age
Care Needed or Requested
Pet 4
Breed/Type of Pet
Please specify breed/type of pet (Pug, Chihuahua, Cat, Bunny, etc.)
Name of Pet
Sex
Age
Care Needed or Requested
Type of Service Requested:

DentalMedical Care by VeterinarianEmergency CareLab Work or Other Diagnostic TestAnnual Exams, VaccinationsUnusual Medical Procedures or Medications, such as on-going treatment for diabetes, etcEuthanasia Services
Estimated Cost for Items Selected:
The information provided above is accurate. I understand that the Smernoff Funding is limited and I may not receive assistance, even if I qualify, if there is no more funding available for the current fiscal year. Final approval is at the discretion of the agency administering the Smernoff Funds and The Community Foundation Serving the Counties of Riverside and San Bernardino.
Signature*

Clear
Date*

MonthDayYear
Date
To expedite grant approval, please upload the following required documents
1. One document proving income level (i.e. monthly checking statemend, current year SSI Benefit Award Letter, unemployment statement). Eligibility: Maximum month income $2000 per one person.
2. Proof of residency (utility bill or rent receipt)
3. Proof of pet ownership, if you have it (previous vet record, photo, license)
4. Copy of Driver's License or Idenfication Card
You may also email the files seperately to samantha@afv.org.

You can also turn in your documents in person to Animal Friends of the Valleys @ 33751 Mission Trail, Wildomar, CA 92595 during opening hours.
File Upload

Cancelof
Which pet(s) currently need veterinary care? Please include type of animal, name of pet, sex, age, and care needs.
Should be Empty:

Which pet(s) currently need veterinary care?

To expedite grant approval, please upload the following required documents