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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?

Dog Cat

7.) Name of Dog/Cat:

8.) Age of Dog/Cat:

9.) Breed Type:

10.) Gender:

Male Female

11.) Weight of Dog/Cat in pounds:

12.) Is Dog/Cat spayed/neutered?

Yes No

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

Please upload a copy of the Vet invoice:

Invoice File #1

Invoice File #2

Invoice File #3

14.) Amount needed for Medical Grant:

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

Yes No

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

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

Image #1

Image #2

Image #3

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

18.) Additional comments:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

April 26, 2021 9:49 am EDT

House 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 EDT

Sher 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 EDT