Apply for Assistance

PLEASE ANSWER ALL QUESTIONS COMPLETELY. QUESTIONS WITH A RED ASTERISK (*) ARE REQUIRED. LEAVING OUT REQUIRED INFORMATION WILL DELAY APPROVAL OF YOUR APPLICATION. CLICK SUBMIT AT THE BOTTOM ONCE COMPLETED.

ACAP IS DESIGNED TO HELP PET OWNERS WITH BASIC, PREVENTATIVE AND INTERVENTIONAL VETERINARY NEEDS ONLY AND CAN NOT HELP WITH THE COST OF SPECIALTY OR
ALTERNATIVE CLINICS AND THERAPIES.

PLEASE NOTE THAT WE CURRENTLY SERVE THE CENTRAL VIRGINIA AREA ONLY

FOLLOWING ARE LINKS TO LISTINGS OF ORGANIZATIONS THAT DO WHAT ACAP DOES IN OTHER AREAS OR NATIONWIDE

Speaking for Spot - http://www.speakingforspot.com/index.php?p=Financial-Assistance-for-Veterinary-Care

Community Animal Rescue Effort (C.A.R.E.) - https://carenorthshore.org/pet-financial-aid/

YOUR INFORMATION

* Indicates required field

APPLICANT'S FULL NAME (Include your former name if different when we helped you in the past) *

What COUNTY do you live in? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

How did you hear about ACAP? *

Have we ever helped you before? *

If so, which pet(s) did we help and when? *

Do you have transportation to/from a vet's office? (ACAP primarily uses veterinarians in the Charlottesville and Richmond areas) *

CURRENT ANIMALS IN YOUR HOUSEHOLD
Select the number of each type of animal in your household whether owned by you or someone else. Provide additional information in the box below if needed.

Dogs kept as pets *

Dogs kept for hunting *

Cats *

Birds *

Rabbits *

Reptiles *

Livestock *

Other - please explain *

Additional information *

SPAY/NEUTER REQUIREMENT

ACAP strives to encourage responsible pet ownership. Our program requires proof that ALL of your pets are spayed (females) or neutered (males) to be eligible for assistance. If any of your pets are not spayed or neutered, we will refer you to free or low-cost spay/neuter clinics in the area. We will not provide assistance to anyone breeding animals.

Are all of the pets in your household spayed and/or neutered? *

If not, do you agree to spay and/or neuter all of the pets in your household? *

ABOUT OUR PROGRAM
ACAP provides financial assistance to low-income and disadvantaged pet owners to prevent unnecessary suffering of pets and to avoid surrender of pets due to manageable conditions or financial hardship.

ASSISTANCE WE PROVIDE, COPAYS
ACAP assists clients by arranging basic preventive and interventional veterinary care such as vet visits, diagnostic testing, vaccinations and prescribed medications. Services are provided through our network of veterinary partners in our service area. We provide flea/tick, heartworm preventative and dewormer medications. ACAP covers $200 of treatment costs per pet, per year; clients are responsible for a copay of $10 per approved vet visit and $5 per medication for flea/tick, heartworm preventative and dewormer medications. Vet visit copays are payable to the vet office at the time of service. Medication copays are payable to ACAP when medications are received. Pet food can be provided at no cost on an emergency basis.

ACAP will coordinate and schedule all veterinary services and visits in advance and will pay our partner providers directly, less any applicable copay. Failure to show up for a scheduled visit, late cancellations of scheduled visits, excessive cancellations of scheduled visits and improper behavior by the client toward ACAP staff or our partners may result in denial of assistance, at the sole discretion of the ACAP Board.

LIMITATIONS ON ASSISTANCE
ACAP program guidelines limit assistance to a maximum of three (3) pets per client, per year and a maximum limit of $200 per pet, per year.

The care and assistance provided by ACAP is not comprehensive and is not meant to be a substitution for regular, preventative veterinary care. We are an all-volunteer organization and are not equipped to adequately respond to emergency situations.

Should a veterinarian determine that additional conditions are present in a client's pet or if any unexpected emergency situation should arise during an ACAP-arranged vet visit, the client is medically and financially responsible for any additional treatments or services they agree to and any resulting complications unless pre-approved in writing (email, text, instant message) by an ACAP representative.

Should circumstances warrant denial of assistance now or in the future for any reason, ACAP reserves the right to do so at the sole discretion of the ACAP Board. Eligibility for assistance may be terminated if clients acquire new animals after being approved for assistance as this suggests financial means.

I AGREE THAT I HAVE READ AND UNDERSTAND THE PROGRAM TERMS AND LIMITATIONS PRESENTED ABOVE *

PET #1 INFORMATION

Pet #1 - Name *

Pet #1 - Dog or Cat? *

Pet #1 - What breed (if dog)? *

Pet #1 - Age *

Male or Female? *

Pet #1 - Age in Years or Months? *

Pet #1 - Is this pet spayed or neutered? *

Pet #1 - Weight (approximate) *

Pet #1 - Color *

Pet #1 - How long have you had this pet? *

Pet #1 - When was this pet last seen by a Veterinarian? *

Pet #1 - Does this pet have a CURRENT Rabies vaccination? *

Pet #1 - What does your pet need at this time? *

Pet #1 - Upload an image of your pet's vet records, rabies certificate, etc. (you may email this to us instead at apply@acapva.org with your name and your pet's name) *

Max file size: 20MB

Pet #1 - Upload an image of your pet (you may email this to us instead at apply@acapva.org with your name and your pet's name) *

Max file size: 20MB

PET #2 INFORMATION

Pet #2 - Name *

Pet #2 - Dog or Cat? *

Pet #2 - What breed (if dog)? *

Pet #2 - Age *

Male or Female? *

Pet #2 - Age in Years or Months? *

Pet #2 - Is this pet spayed or neutered? *

Pet #2 - Weight (approximate) *

Pet #2 - Color *

Pet #2 - How long have you had this pet? *

Pet #2 - When was this pet last seen by a Veterinarian? *

Pet #2 - Does this pet have a CURRENT Rabies vaccination? *

Pet #2 - What does your pet need at this time? *

Pet #2 - Upload an image of your pet (you may email this to us instead at apply@acapva.org with your name and your pet's name) *

Max file size: 20MB

Pet #2 - Upload an image of your pet's current rabies certificate (you may email this to us instead at apply@acapva.org with your name and your pet's name) *

Max file size: 20MB

PET #3 INFORMATION

Pet #3 - Name *

Pet #3 - Dog or Cat? *

Pet #3 - What breed (if dog)? *

Pet #3 - Age *

Male or Female? *

Pet #3 - Age in Years or Months? *

Pet #3 - Is this pet spayed or neutered? *

Pet #3 - Weight (approximate) *

Pet #3 - Color *

Pet #3 - How long have you had this pet? *

Pet #3 - When was this pet last seen by a Veterinarian? *

Pet #3 - Does this pet have a CURRENT Rabies vaccination? *

Pet #3 - What does your pet need at this time? *

Pet #3 - Upload an image of your pet's vet records, rabies certificate, etc. (you may email this to us instead at apply@acapva.org with your name and your pet's name) *

Max file size: 20MB

Pet #3 - Upload an image of your pet (you may email this to us instead at apply@acapva.org with your name and your pet's name) *

Max file size: 20MB

IMAGE RELEASE: ACAP requests permission to use images you've provided in this application for various purposes as examples of the pets we assist. ACAP receives grant money and at times, these agencies will also ask us to share both photos and brief stories of the pets we help with their financial support. Client names will not be released. By my selection below, I give my permission to ACAP to use as they wish images of: *

Upload any additional images we may use for this purpose *

Max file size: 20MB

Upload any additional images we may use for this purpose *

Max file size: 20MB

ELIGIBILITY VERIFICATION
The ACAP program was designed to provide financial assistance to low-income and disadvantaged pet owners. Participation in the program requires verification of your financial eligibility. YOU MUST INCLUDE FINANCIAL INFORMATION WITH YOUR APPLICATION OR IT WILL NOT BE CONSIDERED.

Please answer the following questions and provide proof of financial need by uploading supporting documents such as check stubs or bank statements showing amounts of deposits, copies of your government assistance program approval letters, or other documentation as requested by ACAP for the purpose of determining your eligibility. You may email this to us instead at apply@acapva.org. Please blackout account numbers and other sensitive information for your protection.

How many adults reside in your household (18 years old and older)? *

How many children reside in your household (0 - 17 years old)? *

Do you own or rent your residence? *

How much is your monthly mortgage/rent? *

WHO in the household works and HOW MUCH do they earn per week? *

WHO in the household receives child support, alimony or retirement and HOW MUCH do they receive per month? *

WHO in the household receives any government assistance such as SNAP (food stamps), TANF, SSDI (disability), or SSI (social security) and HOW MUCH do they receive per month? *

Upload Proof of Assistance or Income *

Max file size: 20MB

Upload Proof of Assistance or Income *

Max file size: 20MB

Upload Proof of Assistance or Income *

Max file size: 20MB

Upload Proof of Assistance or Income *

Max file size: 20MB

CERTIFICATIONS FOR THIS APPLICATION

I certify that I am the owner of, or acting agent for, all animals I am requesting assistance for in this application for assistance *

Additional information *

I certify that all statements made and information provided in this application for assistance are true and complete to the best of my knowledge. I further understand and agree that ACAP has notified me that they may share some of my information with other organizations. If an ACAP volunteer has completed this electronic application over the phone for me, I give them permission to accept these terms, type my electronic signature and submit this application on my behalf. *

PLEASE TYPE YOUR LEGAL FIRST AND LAST NAME AS IT APPEARS ON YOUR DRIVERS LICENSE, SOCIAL SECURITY CARD, OR STATE ISSUED ID *

Submit

Apply for Assistance

PLEASE ANSWER ALL QUESTIONS COMPLETELY. QUESTIONS WITH A RED ASTERISK (*) ARE REQUIRED. LEAVING OUT REQUIRED INFORMATION WILL DELAY APPROVAL OF YOUR APPLICATION. CLICK SUBMIT AT THE BOTTOM ONCE COMPLETED.​

PLEASE ANSWER ALL QUESTIONS COMPLETELY. QUESTIONS WITH A RED ASTERISK (*) ARE REQUIRED. LEAVING OUT REQUIRED INFORMATION WILL DELAY APPROVAL OF YOUR APPLICATION. CLICK SUBMIT AT THE BOTTOM ONCE COMPLETED.