House With A Heart: Medical Grant Dog/Cat



1.) Name of Non-Profit Rescue responsible for dog/cat:

2.) NEW POLICY: Grants will be paid directly to the Rescue. Please fill in address to mail check. (Please note that the address listed below MUST match the address listed on the submitted invoice, Guidestar, or organization website.)

Street Address:  

City:   State:  

Zip/ Postal Code:  

3.) Your Name:  

4.) Phone:  

5.) Email:  

6.) Is this for a Dog or a Cat?

7.) Name of Dog/Cat:  

8.) Age of Dog/Cat:  

9.) Breed Type:  

10.) Gender:

11.) Weight of Dog/Cat in pounds:  

12.) Is Dog/Cat spayed/neutered?

13.) What medical issues do you need the Grant for?

Please upload a copy of the Vet invoice:

14.) Amount needed for Medical Grant:  

15.) You agree to give regular updates and pictures for this Dog/Cat.

16.) Please upload 3 images of Dog/Cat:

***Allowed file extensions are jpg, gif, png, pdf***

17.) Please describe the Dog/Cat's back story and how they came to your rescue:  

18.) Additional comments:

 

Leave this empty:

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Signature Certificate
Document name: House With A Heart: Medical Grant Dog/Cat
lock iconUnique Document ID: dba1046c91447fa3a7f448013946aff4cc845936
Timestamp Audit
April 26, 2021 9:49 am ESTHouse With A Heart: Medical Grant Dog/Cat Uploaded by Fiscal Sponsorship - fsp@unitedcharitable.org IP 72.73.25.226
September 20, 2021 2:08 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 108.28.172.231
January 19, 2022 9:26 am ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
January 19, 2022 9:37 am ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
January 19, 2022 9:42 am ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
April 22, 2022 11:34 am ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
May 2, 2022 2:37 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
May 9, 2022 9:26 am ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
February 22, 2023 4:46 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
February 22, 2023 4:57 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
February 22, 2023 4:58 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
February 22, 2023 5:00 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226
February 22, 2023 5:22 pm ESTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226