STEP 1:  Request for Assistance  

EVERY FIELD MUST BE COMPLETED.  Failure to answer all questions will likely generate an Auto-Denial.  At best, it will cause a delay in our ability to consider your request.  Provided you have completed the entire form, a Grant Review Manager will review your request for assistance and respond within 12 hours.  Please check your email account several times each day until you receive a final answer from us.  We will either prequalify your case to continue through the application process or we will send you a denial notice.  There are several factors that are taken into account when determining whether or not a case can be funded, including but not limited to the amount of available funds for distribution at the time of application.  Our program is still very small compared the need that exists.  

Thank you for contacting Brown Dog Foundation.  We are an organization dedicated to helping families who find themselves in a temporary financial crisis at the same time their pet requires life-saving treatment or life-sustaining medications.  We are designed as a one-time benefit.  We are committed to ensuring we help maintain and strengthen the bond between pets and their families during times of unexpected financial crisis.  As a result, if your application is approved and funded,  we will require very detailed information and long-term commitments.    Because our average gift is in excess of $1,000, we will require paper-proof of the following if your case is Prequalified: 

Proof of Income (IRS Tax Return Form 1040s + Recent Paycheck Stubs for all working adults in the household where the pet resides

AND proof of the hardship you claim (if your income exceeds 300% of the Federal Poverty Guidelines

OR a Social Security Statement for the pet-owner

AND proof that you own the animal need which can be determined with Adoption/Purchase Papers, Vet Records and/or Rabies Certificates for two consecutive "terms"

AND at least one photo of your pet with at least one member of the family

AND a brief story about how your pet came to live with you and how you came to need Brown Dog's help

First Name  Last Name
Address  City
State/Province  Zip
Email  Phone

The animal in need is my pet.: (check this box if you can prove with legal documents that the animal in need is your pet)

Urgency:   --None--Hot - need answer within 1 dayWarm - need answer within 5 daysCold

Brown Dog Foundation is not like most organizations who offer a small, token amount to most anyone who asks.  We provide financial assistance, meaning if we cannot truly "bridge the gap between the cost of medical care and saving your family pet" we will deny your case.  Therefore, we REQUIRE that you answer all questions on this form and IF prequalified, we require full financial disclosure for your household. 

What is the estimated cost for treatment:  $ (numbers only, you MUST enter the total retail amount you have been quoted.  If you leave this blank, your request will be denied)

What amount can you pay?:  $  (numbers only, you MUST enter an amount - all Grant Recipients of our program are required to pay something, at least 25%, toward treatment)

Have you adopted a pet in past 12 mos?:  (check this box if you have purchased, adopted or rescued a pet within the last 12 months)

Date most recent pet was acquired?:  (enter the date on which you acquired your most recent pet - use mm/dd/yyyy format)

How old is the pet in need?:  --None--Less than 4 months old4 months to 1 year old1-5 years old5-10 years old10+ years old

Because our program offers full financial assistance, you must disclose the combined household income for your family.  This includes those sharing a residence - whether you are in a relationship or just roommates.  This is how we qualify each applicant into our various programs.

Number of people in family?:  --None--1 (just me)2 (me plus one other)3 (me plus two others)4 (me plus three others)5 (me plus four others)6 (me plus five others)7 (me plus six others)8 (me plus seven others)9 (me plus eight others)10 (me plus nine others)

Last year's household income?:  $  (numbers only, enter the amount reported on your 2011 Tax Return for ALL adult members of your household)

Household income from 2 years ago?:  $  (enter the amount reported on your 2010 Tax Return for ALL adult members of your household)

How many dogs do you own?:    --None--0123456 or more   How many cats do you own?:--None--0123456 or more

My pet in need is already spayed/neutered.:    (check this box if your pet is already spayed/neutered)

My pet in need is not spayed/neutered because:  --None--my pet is too youngmy pet has been too sickI plan to breed at least one litterI can't afford itI don't believe in it

Please check each box that applies to your current situation (if TRUE, check the box):

I am currently employed.:      I am currently unemployed.:
I do not breed dogs or cats.:  (check this box if you have NEVER intentionally impregnated one of your pets)   

I do not show my pets.:   (check this box if you have NEVER entered your pet into an Agility or Breed-Specific Contest)

We do not qualify for a credit card.:      We do not have pet insurance.:

Brown Dog Foundation makes every effort to keep your pet under the care of your primary Veterinarian.  For pet owners who live in close proximity to Nashville TN, we may, on occasion, direct you to one of our Partner Veterinarians for diagnostics and/or treatment.  Therefore, the contact information for your Veterinarian is required, including their Email Address.  Our approval system is now automated and their email is required. 

If your doctor is referring you to a specialist OR you have taken your pet to an Emergency facility - please list their contact information in the NOTES box.

Your Regular Veterinarian's Name: 
Your Regular Clinic Name: 
Clinic Address: 
Vet's Phone:    Vet's FAX Number: 
Doctor's Email: 

 
NOTES & Description of pet's medical needs: