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  STEP 1:  Request for Assistance

**  New Policy, effective January 1, 2014:  Incomplete requests will be automatically denied.  Specifically if any piece of required information is left blank, we will not be able to assist (this includes, but is not limited to the clinic's email, accurate income details, cost of treatment, etc).  All fields are required on this Request Form.  The most common omission is the clinic's email address.  We have come to understand that in order to get an email address for most clinic's you will likely need to explain to them that you are applying for assistance and it's our only method of communication at this time.

Additionally, if you do not have a regular veterinarian, it is highly unlikely we will be in a position to assist you at this time.  Highest priority is given to those families who have a regular doctor. 

EVERY FIELD MUST BE COMPLETED.  If the field asks for a number, enter numbers only.  Do not use special characters.  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.  

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 onset 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 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

We are a US non-profit only.  Requests from outside the United States will be automatically denied.  Our finances change daily.  While the majority of the gifts we make occur within the State of Tennessee, where our organization was founded, we do receive donations daily from other parts of the country.  We are actively fundraising nationwide, however, we are a volunteer program that is not fully funded.  If we don't take in donations, we cannot offer assistance. 

If your request does not meet our Standard Guidelines, you will receive an immediate and automated denial email.  Our guidelines are based on three sets of criteria - our Responsible Pet Owner Standards, the pet's crisis and your household financials.  As a result, we need you to answer every question honestly and completely.  Please do not elaborate within the fields for specific questions.  Use the Description area to provide any additional information you wish.

 

 
 
 
 


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

Urgency:  


Describe the situation:


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 or enter a range or any other character that is not a number, your request will be auto-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)

What is the amount you have secured in donations from others?: (numbers and decimal point only.  If you have not received donations from others, please enter 0)
What is the amount your Insurance Policy will Reimburse? (numbers and decimal point only.  If you do not have insurance for your pet, please enter 0)

Have you adopted or rescued a pet in past 12 mos?:

Date most recent pet was acquired?:  (enter the date on which you acquired your most recent pet - use mm/dd/yyyy format.  use the 1st day of a month if you are uncertain of the date)

How old is the pet in need?: 

How long have you owned your pet?: 

Because our program offers full financial assistance, you must disclose the combined household income of all adults.  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?: 

Projected household income this year?:  $   (numbers and decimal only, add together the income for ALL adult members of your household. If you leave this blank or enter a range or any other character that is not a number, your request will be auto-denied)

Last year's household income?:  $  (numbers and decimal only, enter the amount reported on your 2013 Tax Return for ALL adult members of your household.  If you leave this blank or enter a range or any other character that is not a number, your request will be auto-denied)

Household income from 2 years ago?:  $  (enter the amount reported on your 2012 Tax Return for ALL adult members of your household.  If you leave this blank or enter a range or any other character that is not a number, your request will be auto-denied)

How many dogs do you own?:       How many cats do you own?:

Year of most recent rabies vaccine for the pet in need.: 

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: 


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

I am currently employed:      I am currently unemployed or rely on government assistance:    
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 which makes their contact information, including email, 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 (name of clinic, name of doctor, address, phone, fax and office email) in the NOTES box.


Your Regular Veterinarian's Name:    (leave blank if doctor's rotate)
Your Regular Clinic Name: 
Clinic Address: 
Vet's Phone:    Vet's FAX Number: 
Clinic or Doctor's Email: 

 
NOTES & Description of pet's medical needs and/or Specialist's contact information: