HPPL Voucher Request

HPPL Voucher Request

Submitting this voucher request does not guaranty services.
CatDog
FemaleMale
Approximate age of pet?*
Approximate weight of pet?*
YesNo
Your Name*

First NameLast Name
Email*
example@example.com
Please explain why you need assistance.*
Brazoria CountyChambers CountyFort Bend CountyHarris CountyLiberty CountyMontgomery CountyWaller CountyOther
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social SecurityUnemploymentFood Stamps/SNAPTANFMedicaidCHIPSSIWIDAABDPublic Housing or Section 8 HousingLow Income Energy AssistanceTelephone LifelineCommunity Care via DADSLIS in Medicare ("Extra Help")Needs-based VA PensionChild Care Assistance under Child Care and Development Block GrantCounty Assistance, County Health Care or General AssistanceNone of the Above
Upload proof of benefits.*

Cancelof
By accepting help through this program, you agree you will not give away or sell any vouchers or items given to you. Vouchers are non-transferrable. You must provide a photo id matching your voucher at check-in. You also agree we may use your story, including photos, for grant writing and fundraising purposes. Filling out this form does not guarantee assistance.
Please type your name to agree to these terms.*
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