Special Assistance Fund Application

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The Special Assistance Fund (SAF) supports owners with financial hardship who have a pet needing medical attention. As a nonprofit organization, the Connecticut Humane Society and its public medicine clinic rely 100% on donations. We receive many requests for financial support above and beyond the reduced service fees (which are made possible by donor support). The SAF tries to provide additional aid for those who are in the most financial need or who would likely feel they have to rehome their pet if they do not receive assistance. The requested information helps determine how CHS can best use the SAF to benefit pets in need. Please understand this program is not meant for emergency situations. The application process may take up to 14 days to be completed.

Have you contacted CHS about your need for assistance already?(Required)

Please enter the hotline number from your call:(Required)

Please reach out to the Connecticut Humane Society at 860-594-4500 to speak to a representative before completing this form. Applications submitted without an initial phone call will not be processed.

You must complete all information. Incomplete applications will not be processed and may delay your pet's care. DO NOT hit "enter" until all fields have been filled out.

Your Information

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Phone Type(Required)

Number of adults in the home (including yourself):(Required)

Relation of other adults to you:(Required)

Number of children in the home, their ages, and relationship to you:(Required)

Number, types, and ages of other pets in the home:(Required)

Pet's Information

Name of the pet(s) that needs assistance:(Required)

Species:(Required)

What species is your pet?(Required)

Pet's age:(Required)

How long have you owned this pet?(Required)

What treatment do you need help with?(Required)

Estimated Cost of Care?(Required)

How much can you pay toward this care?(Required)

Are you receiving other funding for your pet's care?(Required)

What is the amount of funding you are receiving?(Required)

What is the source of this other funding?(Required)

How much financial assistance are you requesting?(Required)

Household Income

What is your Employment Status?(Required)

Adult 2's Employment Status?(Required)

Adult 3's Employment Status?(Required)

Adult 4's Employment Status?(Required)

Place of Employment(Required)

Adult 2's Place of Employment(Required)

Adult 3's Place of Employment(Required)

Adult 4's Place of Employment(Required)

Total take-home pay (after taxes and deductions) per month:(Required)

Adult 2's Total take-home pay (after taxes and deductions) per month:(Required)

Adult 3's Total take-home pay (after taxes and deductions) per month:(Required)

Adult 4's Total take-home pay (after taxes and deductions) per month:(Required)

Do you, your partner, or other adult household members/pet owners collect:(Required)

Social Security

Disability

General Assistance

Unemployment

Alimony

Child Support

Other

None of the above

If other:(Required)

If yes to any of the above, what is the total amount receiving per month?(Required)

Total take-home pay per month:(Required)

Household Expenses

How much do you pay in mortgage per month?(Required)

(Enter $0 if not applicable)

How much do you pay in rent per month?(Required)

(Enter $0 if not applicable)

How much do you pay in electric per month?(Required)

(Enter $0 if not applicable)

How much do you pay in gas/oil per month?(Required)

(Enter $0 if not applicable)

How much do you pay in phone bills per month?(Required)

(Enter $0 if not applicable)

How much do you pay in cable per month?(Required)

(Enter $0 if not applicable)

How much do you pay in insurance per month?(Required)

(Enter $0 if not applicable)

How much do you pay in auto expenses per month?(Required)

(Enter $0 if not applicable)

How much do you pay in child support per month?(Required)

(Enter $0 if not applicable)

How much do you pay in alimony per month?(Required)

(Enter $0 if not applicable)

Please list any other expenses or debt you may have:(Required)

Narrative

Please share some information about your pet, your relationship with your pet, you pet's illness or accident, and any other information that you'd like us to know. Please also share a bit about why you are requesting financial aid and how the Special Assistance Fund can help you.(Required)

Sample Narrative: Dear Connecticut Humane Society: (Paragraph 1): Tell us about your pet. How long this pet has been part of your life? What makes your pet special? (Paragraph 2): Describe your pet's illness or accident. How did it happen? What have you tried to fix the problem? (Paragraph 3): Tell us about your financial situation. Why are you requesting special assistance, and how would it help?

Medical Records & Pet Photos

Upload all medical records, estimates, and bills you have relative to this funding request.(Required)

Drop files here or

Max. file size: 256 MB.

Please upload 2-3 photographs of your pet.(Required)

Drop files here or

Max. file size: 256 MB.

Other Funding Sources

If you have not yet explored other funding options, visit CThumane.org/FinancialResources to learn more.

Please select all other funding sources you have tried:(Required)

Grants

Line of Credit

Credit Card

Scratch Pay

Care Credit

Family/Friends

Other

None

What was the result of your grants request?(Required)

What was the result of your line of credit request?(Required)

What was the result of your credit card request?(Required)

What was the result of your Scratch Pay request?(Required)

What was the result of your Care Credit request?(Required)

What was the result of your family/friends request?(Required)

Please describe what other funding source you have tried and the result of that request:(Required)

Acknowledgements

We will treat you and your pet with courtesy and respect and we expect the same in return. Sharing the good work of CT Humane Society’s Clinic is key to inspiring the community to support this program and make it available for pets in need. CT Humane Society’s Clinic may use photos of your pet(s) and their name(s) for this purpose. We will not use confidential owner information, like your name, without your consent.

I give CT Humane Society permission to use the following personal/owner information if my pet is selected to be featured in a story:(Required)

Do you give permission for the Connecticut Humane Society to use photos that include people and/or your pet(s)?(Required)

I attest that the above pet(s) is owned by me and that the information provided on this application is true and accurate to the best of my knowledge:(Required)

(Type your first and last name here for an electronic signature.)

Which CHS location is closest to you?(Required)

Your form will be sent to the selected location.

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Special Assistance Fund Application