The Dr. Bill Haines 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 veterinary clinics rely 100% on donations. We receive many requests for financial support. The requested information on this application helps determine how CHS can best use the SAF to benefit you and your pet. Please understand that we do our best to respond timely in urgent circumstances, but this program is not meant for emergency situations. We strive to respond to applications within 48 hours, but it may take up to 14 days to be reviewed and receive a response. Have you contacted CHS about your need for assistance already?((Required)YesNoWhat is your hotline number?You must complete all information. Incomplete applications will not be processed and may delay your pet’s care.Part I. QuestionnaireYour Name(Required) First Last Date(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Which pet resource center are you closest to?(Required)Newington (701 Russell Road)Waterford (169 Old Colchester Road)Wilton (863 Danbury Road)Email(Required) Phone(Required)Phone Type(Required)CellHomeOtherNumber of adults in the home(Required)Number of children in the home(Required)Number, types, and ages of other pets in the home(Required)Are you 65 years of age or older?(Required)YesNoAre you a veteran?(Required)NoYesHow did you hear about this program?(Required)Your Pet's InformationPet Name:(Required)This pet is a(Required)DogCatOtherSpeciesBreed(Required)Age(Required)How and when did you get this pet?(Required)Why does your pet need medical treatment?(Required)Please attach the medical record from your pet's veterinary visit:Max. file size: 256 MB. Do you have a written estimate from a veterinarian showing how much the treatment will cost?(Required)YesNoIf yes, please provide a copy of the estimate with this application.Max. file size: 256 MB. If no, when was this condition diagnosed and at what veterinary hospital?What amount can you pay toward the care of your pet?(Required)How much financial assistance are you requesting?(Required)Are you receiving other funding for your pet's care?(Required)YesNoIf yes, please explain:(Required)If approved for a line of credit for this treatment, how much can you afford for a monthly payment?(Required)Household IncomeAre you employed?(Required)Full-timePart-timeUnemployedYour take-home pay (after taxes and deductions) per month(Required)Are any other household members employed?(Required) Full-time Part-time Unemployed Other Check all that applyIf other, please explain:Other household members total take-home pay (after taxes and deductions) per month(Required)Do you or any other adult household members collect(Required) Social Security Disability General Assistance Unemployment Alimony Other Check all that applyIf other, please explain:If yes, total amount received each month:Household ExpensesDo you pay any of the following?(Required) Mortgage Electric Phone Other Insurance Child Support Rent Gas/Oil Cable Car Payment Alimony Check all that apply.Mortgage AmountElectric AmountPhone AmountOther Insurance AmountChild Support AmountRent AmountGas/Oil AmountCable AmountCar Payment AmountAlimony AmountPlease list any other expenses or debts you might have(Required)Ex: credit cards, debt consolidation, etc.Funding SourcePlease indicate if you've tried any of the following alternative funding sources.Personal Savings(Required)Did not tryApprovedDeclinedPersonal Savings Approved for:(Required)$Credit Card(Required)Did not tryApprovedDeclinedCredit Card Approved for:(Required)$Scratch Pay(Required)Did not tryApprovedDeclinedScratch Pay Approved for:(Required)$Care Credit(Required)Did not tryApprovedDeclinedCare Credit Approved for:(Required)$Cherry(Required)Did not tryApprovedDeclinedCherry Approved for:(Required)$Family/Friends(Required)Did not tryApprovedDeclinedFamily/Friends Approved for:(Required)$Other(Required)Did not tryApprovedDeclinedOther Approved for:(Required)$If other, explain:Please attach photos of your pet(Required)Max. file size: 256 MB. Part II. NarrativePlease share some information about your pet, your relationship with your pet, your 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 assist you.Tell us about your pet. How long has your pet been a part of your life? What makes your pet special?(Required)Describe your pet's illness or accident. How did it happen? What have you tried to fix the problem?(Required)Describe your financial situation. Why are you requesting special assistance and how would it help?(Required)Part III. AcknowledgementsConsent(Required) I agree.CHS will treat you and your pet with courtesy and respect and expects the same in return.Permissions(Required)All InformationPet's Name OnlyFirst Name OnlySharing 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 above personal/owner information if my pet is selected to be featured in a story: Electronic Signature(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.
