Home For Life Grant Application I have read agree with the above.* Yes Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Employment InformationIf employed, name of employer* Employer PhoneAnnual Income* Income SourceIncome From* Disabilty SSI Welfare Unemployment Other Other - Please ExplainNumber of DependentsWas Care Credit applied for?* Yes No Care Credit Reference Number* Can owner contribute to cost of care for the pet?* Yes No If yes, how much money can owner pay directly to the service provider?* Do you own or rent your home?* Own Rent If you rent please provide the name and phone number of your landlord/apartment managerLandlord's Name* Landlord's Phone*Your Pet's Name* Your Pet's Age* Your Pet's Sex*FemaleMaleYour Pet's Breed*CatDogOtherSpayed/Neutered*SpayedNoneNeutered*If your pet was not spayed or neutered please explain why.*How was your pet acquired?Name and Phone number of veterinarian* Reason service/treatment is required: (emergency boarding, spay/neuter, hit by car/broken bone(s), pyometra, etc.). If pet has seen veterinarian please give name and phone number of veterinarian and if any services were given other than an examination.*Estimated Cost of Treatment* Estimated Cost of TreatmentIf applying for our emergency boarding/foster care grant, please provide us with an estimate of how long your pet will be in our program (up to 60 days) If applying for our emergency boarding/foster care grant, please provide us with an estimate of how long your pet will be in our program (up to 60 days)Applicant:Please write a brief explanation of your current situation which has led you to ask for funding from STARelief and Pet Assistance in order to obtain emergency veterinary care, boarding/fostering for your pet.*I understand that STARelief and Pet Assistance, Inc. assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnoses, treatments, products or services and hereby waive any and all claims for liability against STARelief and Pet Assistance, Inc. I understand any documentation or pictures given to STARelief and Pet Assistance, Inc. cannot be returned. I certify that the information given by me in this application is true and complete. I further understand that any falsified information that I provide will terminate the reviewing process immediately. I hereby authorize release/disclosure of records and/or other information concerning the above inquiries, including but not limited to employment information, tenancy information, and veterinarian records. STARelief and Pet Assistance, Inc. reserves the right to refuse any application it considers unsatisfactory. We also require that you allow us to include any, all or part of your story and picture of your pet in our newsletter, website, Facebook, etc. (The story will not include your real name) By signing below I understand and agree to STARelief and Pet Assistance’s boarding/foster care terms and conditions. By signing this application, you agree, under the penalty of perjury, to the above contract, and confirm that all information provided is the truth to the best of your knowledge.Upload an image of your pet. Upload a JPEG, PDF, GIFF or PNG file.*Max. file size: 16 MB.Please provide proof of financial hardship. Upload a JPEG, PDF, GIFF or PNG file.*Max. file size: 16 MB.Estimate from your veterinarian. Upload a JPEG, PDF, GIFF or PNG file.*Max. file size: 16 MB.Print Name of Applicant* How did you hear about STARelief* Date* MM slash DD slash YYYY ALL required fields must be filled in otherwise your application will not go through. Please check yes if you have filled in ALL the required fields.* Yes Signature*STARelief and Pet Assistance does not retain any sensitive or confidential informationNameThis field is for validation purposes and should be left unchanged.