House With A Heart: Medical Grant Dog/Cat



1.) 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.

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: 68474b0d902afcc8aac7f5865cf4f6366db07039
Timestamp Audit
April 26, 2021 9:49 am EDTHouse 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 EDTSher 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 EDTSher 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 EDTSher 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 EDTSher 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 EDTSher 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 EDTSher 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 EDTSher Polvinale - hwahsher@gmail.com added by Fiscal Sponsorship - fsp@unitedcharitable.org as a CC'd Recipient Ip: 72.73.25.226