Shadow Fund - Request For Financial Assistance

Request For Financial Assistance

The Shadow Fund
REQUEST FOR ASSISTANCE

Submission for financial assistance for emergency medical purposes can be done at any time, but still must follow the guidelines found below under the application process.

Due to the very nature of being an emergency, it is recommended that the application and situation be relayed to the Police Liaison through electronic means by using this form

CENTRAL INDIANA K9 ASSOCIATION, INC.'s ability to provide financial assistance will be directly predicated on the size of the "Shadow Fund" account at the time of the request, keeping in mind the minimum balance requirement and the discretion of the Board of Directors.

Reimbursement for advanced medical care will be considered up to 90 days post care received. The applicant will be required to provide proof of payment and a full description of services received. If the request is being submitted in advance of care being received, payment (if any) can be arranged directly with the healthcare provider. Again, all grants for financial assistance are provided based on CENTRAL INDIANA K9 ASSOCIATION, INC.'s ability to have funds available in the "Shadow Fund."

The party receiving funds will agree, unconditionally, to allow CENTRAL INDIANA K9 ASSOCIATION, INC. to take and use any and all pictures, information related to the application and the grant award to be used for Public Relations and Marketing purposes.

Any waiver request from this requirement will require a written request from the Police Chief or highest ranking officer under whom the canine served or under whom the K9 officer currently serves. This recognizes that some officers may be serving in a special capacity that requires they remain anonymous for security reasons.

Applications for assistance will be forwarded to the Police Liaison or designee. When an application has been received, the Police Liaison or designee will review the application to ensure it is complete. Every attempt will be made to submit to the Board of Directors and acquire a vote within 72 hours. Due to the serious nature and/or emergency timeline, the application and subsequent vote by the Board of Directors can be handled electronically.
Application Date*

MonthDayYear
Date
Owner Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number 1*

Area CodePhone Number
Phone Number 2

Area CodePhone Number
Email*
example@example.com
Past/Current K9 Position:*
Department/Unit name:*
Contact Person *

First NameLast Name
Contact's Phone Number*

Area CodePhone Number
Contact's Email
example@example.com
K9 Name*
K9 Breed*
Recent photo of K9*

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K9 Discipline*

NarcoticsBomb/IEDPatrolTrackingApprehensionSearch/RescueAccelerant/FireOther
Years of service*
Retirement date*
PROOF OF SERVICE REQUIREMENT:

Can be a single letter from the Senior officer or Chief on Department letterhead that shows all three requirement re: K9's service with a specific Department/unit, the date of retirement and the change over of ownership to the name of the person who now has financial responsibility for the K9.
Proof of service, retirement, and ownership - upload*

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K9 certification/s of expertise*

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Explain in detail the advanced medical need for this canine (see note below)*
Veterinary Estimate of Costs - upload*

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Application: All applications should be fully descriptive of the healthcare provided accompanied by documentation from the veterinarian describing the care needed/provided to include diagnosis and prognosis, test results/summary analysis and the completed application.

If seeking reimbursement, the inclusion of receipts showing payment made in full on letterhead from the veterinarian clinic.

Incomplete requests will be automatically denied.
Should be Empty: