Application for Financial Assistance of Veterinary Services

This application is for financial assistance in the case of a pet needing extensive veterinary treatment for a diagnosed disease or injury.
The following documentation is required for consideration:

1) Proof of financial hardship, or SSI or other government financial assistance (WIC, EBT, etc)
2) Driver’s license or state identification
3) Veterinary records (the more records that can be provided the better)
4) An estimate generated by a veterinary clinic for the proposed treatment plan

Approval for funding will be determined at the discretion of the board members of Busters’ Brigade. Please note that Buster’s Brigade will not fund 100% of the estimate and that the percentage or dollar amount will be determined by the board members.
Name of Individual applying for assistance *
First NameLast Name
Home Address*
Street Address
Street Address Line 2
CityState
Zip Code
Home Phone*
Area CodePhone Number
Cell Phone
Area CodePhone Number
Email
example@example.com
Provide a brief summary of your situation and why funding is needed
How much were you approved for?
Name Of Your Veterinarian*
First NameLast Name
Phone Number of Veterinarian or Clinic Used*
Area CodePhone Number
Upload Required Documents
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Signature of Acceptance*
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