Charitable Grant Application

Charitable Grant Application
Part 1: Client and Patient Information
Owner Full Name

First NameLast Name
Pet Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Diagnosed Medical Condition
Part 2: Objective Eligibility Criteria
Please verify each of the following statements:
Please attach a screenshot or copy of the verification of financial hardship to this form.

Cancelof
Please attach a screenshot or copy of the denial notification to this form.

Cancelof
Part 3: Financial Responsibility Parameters
Our local fund is entirely sustained by community donations. To preserve resources for as many families as possible:
1. The Southside Mobile Vet Charitable Fund will cover up to 75% of the treatment estimate (capped at a absolute maximum lifetime grant of $500).
2. The pet owner is legally responsible for paying the remaining 25% balance (plus any costs exceeding the $500 cap) at the exact time medical services are rendered.
3. This grant is strictly limited to a one-time use per household.
Part 4: Agreement & Authorization
I certify that all information provided is accurate and true. I understand the Veterinary Care Foundation handles all tax-compliant administrative distributions for this account.

Terms & Conditions Confirmation: I understand that assistance grants are strictly subject to fund availability and explicitly limited to a single, one-time treatment approval per household. Southside Mobile Vet reserves the right to deny funding for any case based on clinical prognosis or administrative eligibility parameters. I hereby authorize Southside Mobile Vet to release medical details to the Veterinary Care Foundation for verification and audit compliance.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Charitable Grant Application

Part 1: Client and Patient Information

Part 2: Objective Eligibility Criteria

Part 3: Financial Responsibility Parameters

Part 4: Agreement & Authorization