Boots & Paws PCS Financial Assistance Application- A 501 (c)(3) Non-Profit Veteran Run Organization

Boots & Paws PCS Financial Assistance Application- A 501 (c)(3) Non-Profit Veteran Run Organization

"Helping Military Families Keep Their Pets Together During PCS Moves." Please complete the form with your PCS and pet details, then attach required PCS, veterinary, and financial documentation that we are requesting.
Applicant Information

Your information
Full Name

First NameLast Name
Branch of Service
Rank
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Duty Station/Base
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
PCS Information
PCS Destination/Base
New Duty Station Address (if known)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Report Date

MonthDayYear
Date
PCS Order Date

MonthDayYear
Date
Expected Move Date

MonthDayYear
Date
Have you received official PCS orders?
Pet Information

Information on your pets
Pet Name Number 1
Species- Pet Number 1

Other
Age (years)- Pet Number 1
Breed- Pet Number 1
Weight (lb)
Spayed/Neutered- Pet Number 1
Microchip Number-Pet Number 1 (They must be Microchipped prior to PCS)
Pet Name Number 2
Species- Pet Number 2

Other
Breed- Pet Number 2
Spayed/Neutered- Pet Number 2
Microchipped- Pet Number 2

Other
Veterinary Information

Please provide your pets Veterinary Informarion
Veterinarian Name

First NameLast Name
Veterinarian Clinic
Clinic Number
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is the pet current on vaccinations? They will need to be prior to PCS-Help is avaiable
Medical Information

Please provide pets medical information
Current Medications
Medical Conditions or Special Needs
Does the pet require special transportation accommodation?

Other
If yes, please explain special transportation accommodations needed
Household Information

Include all requested information requested
Number of Adults in Household
Number of Children in Household
Number of Pets Being Relocated
Financial Assistance Request
What type of assistance are you requesting?

Other
Estimated Total Pet Relocation Cost ($)
Amount Requested from Boots & Paws ($)
Amount you can repay monthly ($)
Financial Information

This is the families information
Monthly Gross Income ($)
Monthly Housing Expenses ($)
Monthly Debt Payments ($)
Are you experiencing financial hardship related to this PCS?
If yes, please explain your financial hardship
Additional Support

Please advise if you've applied to any other programs
Have you applied for assistance through any of these organizations?

Other
If yes, please describe the outcome or status of that application.
Certification
Certification Statement-Jotform Form Specialist

Certification, I certify that the information provided is true and complete to the best of my knowledge. I understand that Boots & Paws may request additional documentation, including PCS orders, Veterinary records, vaccination records, estimates, invoices and proof of financial need.
Applicant Signature
Date

MonthDayYear
Date
Required Documents
PCS Orders

Cancelof
Pet Vaccination Records

Cancelof
Veterinary Estimate or Invoice

Cancelof
Transportation Quote

Cancelof
Proof of Financial Hardship

Cancelof
Photo of Pet(s)

Cancelof
For Boots & Paws Use Only
Date Received

MonthDayYear
Date
Reviewer
Assistance Approved
Amount Approved/Paid To ($)
Notes
Payback
Amount of Payback ($)
Percentage of Payback (%)
Microchipped- Pet Number 1
Should be Empty:

Boots & Paws PCS Financial Assistance Application- A 501 (c)(3) Non-Profit Veteran Run Organization

Applicant Information

PCS Information

Pet Information

Veterinary Information

Medical Information

Household Information

Financial Assistance Request

Financial Information

Additional Support

Certification

Required Documents

For Boots & Paws Use Only