prequal

EVERY FIELD MUST BE COMPLETED. Failure to answer all questions 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.

PLEASE READ BEFORE PROCEEDING WITH THE SURVEY
This is Step 1 of a 5 Step Process
Please refer to the Approval Process page for details

*** If you believe that your pet's life is in immediate danger, you should apply here, but seek immediate assistance from a licensed Veterinarian. We will consider assisting in cases where treatment has already occurred IF the pet's life was truly at risk, provided you complete this questionnaire within 7 days of the injury/illness.

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

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

The animal in need is my pet.: Check this box ONLY if the animal in need belongs to you.

Rating

What is the estimated cost for treatment: $ (required)
What amount can you comfortably pay at the time services are rendered?: $ (please include all cash and credit that you have immediate access to)

Number of people in family?: (required)
What is your projected household income for this year?: $ (required)
Last year's household income (reported on Tax Return)?: $ (required)
Household income from 2 years ago (reported on Tax Return)?: $ (required)

Have you adopted or taken in a new pet in past 12 mos?: If you check this box, please explain below in the field titled Description
Date most recent pet was acquired?: (required)

Please check all that apply to your situation:
I am currently unemployed.:    I am currently employed.:
We do not qualify for a credit card.:     We do not have pet insurance.:
I do not breed dogs or cats.:     I do not show my pets.:

Please tell us the symptoms your pet is displaying OR if diagnosis has already been made, tell us what the diagnosis is:

Brown Dog Foundation is NOT a referral program. If you do not have a regular veterinarian, we may be unable to assist you with a grant at this time.

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