Full Service Financial Assistance Application

Please complete this application AND attach proof of income for all adults in your household. If you do not have any of these documents, contact HFW at 260-744-0454 for clarification. Applicants must be residents of Allen County to be eligible for financial assistance and may receive assistance once per year.

In general, our financial assistance program is not able to assist with veterinary emergencies and chronic illnesses. Each application is reviewed on a case by case basis.

Due to funding constraints, we are not able to approve financial assistance for every applicant.

If an animal is in need of urgent veterinary care, it is the owner’s responsibility to seek care immediately.

Approval of Assistance Applications can take up to 10 business days. One approved application per household per year.

Be sure to check your spam/junk folders for our response!

Acceptable Forms of Proof of Income

To complete the review of an application for financial assistance, clients must provide proof of income for all adults residing in their household. Examples of acceptable documentation include:

For Employed Individuals:

Recent pay stubs
A signed letter on company letterhead detailing their rate of pay and average hours

For Self-Employed Individuals:

The most recent federal tax return (e.g. Schedule C)
Completed FSSA Report of Self-Employment Income forms or business logs

For Unemployed Individuals:

A statement or printout showing your weekly benefit amount from Indiana Unemployment (DWD)

For Other / Fixed Income:

Official award letters for Social Security (SSA), Supplemental Security Income (SSI), VA benefits, or child support documentation

Full Service Veterinary Financial Assistance Application

Name(Required)

First Last

Your Birthdate(Required)

Phone(Required)

Email(Required)

Address(Required)

City(Required)

Zip(Required)

List all pets in your home - even if you don't need services for each animal(Required)

Include For All Pets:

Name
Age
Gender
Cat or Dog
Spayed/Neutered?
Breed

Are your pets up-to-date on vaccines?(Required)

Yes

I don't know

Do you have a current Veterinarian?(Required)

Yes

If so, who is that Veterinarian?

Have you received a diagnosis or estimate for services from your vet?(Required)

Please tell us about your pet's health concerns and the veterinary service(s) your pet needs(Required)

Total Household Income(Required)

Indicate per week, per month, or per year

Number of Adults in the home(Required)

Number of Children in the home(Required)

What type/s of government assistance do you receive, if any?(Required)

Are any of these on behalf of your dependents, if so which?(Required)

Please provide a brief description of the reason you are requesting financial assistance:(Required)

Release and Certification of Information:

For value received, I/we, the owner(s) of the above-designated cats and/or or dogs, do hereby fully and completely release and discharge Humane Fort Wayne and all persons, agents, employees, directors, and officers thereof and/or on its behalf liable from and against any and all actions, causes of action, claims, demands, assertions, contentions, suits, damages, expenses and/or losses of any kind and description which in any manner pertain to, concern, involve or relate to the care and medical treatment of my/our pet(s), including injury or death, and I/we agree to indemnify and hold harmless all entities and persons being released hereunder from and against any and all actions, causes of actions, claims, demands, assertions, contentions, suits, damages, expenses, and losses resulting from the foregoing activities. By my signature below I certify that I understand that HFW's assistance program is for limited income pet owners only, and the information provided is accurate and complete, and that this information is subject to verification prior to approval.

Signature(Required)

Date(Required)

Attach Proof Of Income(Required)

Drop files here or

Max. file size: 256 MB, Max. files: 5.

ie: Disability statement, SSI statement, unemployment statement, or tax return

Attach Vet Diagnosis/Quote

Drop files here or

Max. file size: 256 MB, Max. files: 5.

Please attach if available

Full Service Financial Assistance Application

Acceptable Forms of Proof of Income

Full Service Veterinary Financial Assistance Application

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