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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. PLEASE NOTE THAT WE CANNOT RESPOND IMMEDIATELY, THEREFORE EMERGENCIES OFTEN CANNOT BE ADDRESSED. DUE TO OUR LIMITED FUNDS, ACAP CANNOT HELP WITH THE COST OF SPECIALTY OR
ALTERNATIVE CLINICS AND THERAPIES, NOR CAN WE HELP WITH PETS OTHER THAN CATS AND DOGS.
PLEASE NOTE THAT WE SERVE CENTRAL, SW & OTHER RURAL PARTS OF VIRGINIA ONLY.
CLICK THE LINK BELOW TO SEE LISTINGS OF ORGANIZATIONS THAT HELP 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
*
please include your area code
How did you hear about ACAP?
*
Have we ever helped you before?
*
Please answer Yes or No
Yes (please go to the next question)
No
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)
*
Please select Yes or No
Yes
No
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
*
0
1
2
3
4
5
6
More than 6 - explain below
Dogs kept for hunting
*
0
1
2
3
4
5
6
More than 6 - explain below
Cats
*
0
1
2
3
4
5
6
More than 6 - explain below
Birds
*
0
1
2
3
4
5
6
More than 6 - explain below
Rabbits
*
0
1
2
3
4
5
6
More than 6 - explain below
Reptiles
*
0
1
2
3
4
5
6
More than 6 - explain below
Livestock
*
0
1
2
3
4
5
6
More than 6 - explain below
Other - please explain
*
0
1
2
3
4
5
6
More than 6 - explain below
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?
*
answer yes or no
If not, do you agree to spay and/or neuter all of the pets in your household? (If you answer "yes" ACAP may have funds to help with the cost. If you answer "no" then do not complete the rest of the application)
*
answer yes or no
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. There are several qualifying factors involved in being approved for our program. Please read the following information carefully.
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.
Acquiring additional animals after you have been approved for our program may make you ineligible for our assistance. ACAP feels that if you are asking for financial help with the pets you already have, then you cannot afford to care for more pets.
LIMITATIONS ON ASSISTANCE
ACAP program guidelines limit assistance to a maximum of three (3) pets per client, per year and an average amount of $200-$300 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. Please note that we
cannot
help with veterinary care for the following:
1. Animals other than puppies, dogs, kittens and cats
2. Feral cat colonies
3. Pets who are being bred by their owners regularly (unless owners agree to spay/neuter)
4. Veterinary bills that have already been incurred by owners (ACAP does not help "pay down the balance" of vet bills)
5. Other rescue groups or people seeking veterinary treatment for animals they are planning to rehome
6. Animals who are currently involved in litigation or animal control custody 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
*
YES, I agree to these terms
NO, I do not agree to these terms
PET #1 INFORMATION
Pet #1 - Name
*
Pet #1 - Dog or Cat?
*
-- Please select --
Dog
Cat
Other
Pet #1 - What breed (if dog)?
*
If cat, skip to next question
Pet #1 - Age
*
Pet #1 - Age in Years or Months?
*
-- Please select --
Years
Months
Pet #1 - Male or Female?
*
-- Please select --
Male
Female
Pet #1 - Is this pet spayed or neutered?
*
-- Please select --
Yes
No
I don't know
Pet #1 - Weight (approximate)
*
-- Please select --
1-5 lbs
6-10 lbs
11-20 lbs
21-30 lbs
31-49 lbs
50-75 lbs
75-100 lbs
100-150 lbs
Over 150lbs
Pet #1 - Color
*
-- Please select --
Black
Black & White
Brindle
Brown/Tan
Brown/Tan & White
Calico (cats)
Grey or Grey & White
Cream or White
Tri-Color (black/brown/white/cream or merle)
Orange (cats)
Red (dogs)
Tabby (cats)
Tiger (cats)
Tortoiseshell (cats)
Pet #1 - How long have you had this pet?
*
-- Please select --
Less than 1 month
1 month to 1 year
1 year to 3 years
3 - 5 years
5+ years
Pet #1 - Where did you get this pet?
*
Pet #1 - When was this pet last seen by a Veterinarian?
*
-- Please select --
Less than 1 month ago
1 month to 1 year ago
1 year to 3 years ago
Over 3 years ago
I don't know
Pet #1 - Does this pet have a CURRENT Rabies vaccination?
*
-- Please select --
Yes
No
I don't know
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
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
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
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
PET #2 INFORMATION
Pet #2 - Name
*
Pet #2 - Dog or Cat?
*
-- Please select --
Dog
Cat
Other
Pet #2 - What breed (if dog)?
*
Pet #2 - Age
*
Pet #2 - Age in Years or Months?
*
-- Please select --
Years
Months
Pet #2 - Male or Female?
*
-- Please select --
Male
Female
Pet #2 - Is this pet spayed or neutered?
*
-- Please select --
Yes
No
I don't know
Pet #2 - Weight (approximate)
*
-- Please select --
1-5 lbs
6-10 lbs
11-20 lbs
21-30 lbs
31-49 lbs
50-75 lbs
75-100 lbs
100-150lbs
Over 150lbs
Pet #2 - Color
*
-- Please select --
Black
Black & White
Brindle
Brown/Tan
Brown/Tan & White
Calico
Cream or White
Grey or Grey & White
Tri-Color (black/brown/white/cream or merle)
Orange (cats)
Red (dogs)
Tabby (cats)
Tiger (cats)
Tortoiseshell (cats)
Pet #2 - How long have you had this pet?
*
-- Please select --
Less than 1 month
1 month to 1 year
1 year to 3 years
Over 3 years
Pet #2 - Where did you get this pet?
*
Pet #2 - When was this pet last seen by a Veterinarian?
*
-- Please select --
Less than 1 month ago
1 month to 1 year ago
1 year to 3 years ago
Over 3 years ago
I don't know
Pet #2 - Does this pet have a CURRENT Rabies vaccination?
*
-- Please select --
Yes
No
I don't know
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
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
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
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
PET #3 INFORMATION
Pet #3 - Name
*
Pet #3 - Dog or Cat?
*
-- Please select --
Dog
Cat
Other
Pet #3 - What breed (if dog)?
*
Pet #3 - Age
*
Pet #3 - Age in Years or Months?
*
-- Please select --
Years
Months
Pet #3 - Male or Female?
*
-- Please select --
Male
Female
Pet #3 - Is this pet spayed or neutered?
*
-- Please select --
Yes
No
I don't know
Pet #3 - Weight (approximate)
*
-- Please select --
1-5 lbs
6-10 lbs
11-20 lbs
21-30 lbs
31-49 lbs
50-75 lbs
76-100 lbs
100-150 lbs
Over 150lbs
Pet #3 - Color
*
-- Please select --
Black
Black & White
Brindle
Brown/Tan
Brown/Tan & White
Calico
Cream or White
Grey or Grey & White
Tri-Color (black/brown/white or merle)
Orange (cats)
Red (dogs)
Tabby (cats)
Tiger (cats)
Tortoiseshell (cats)
Pet #3 - How long have you had this pet?
*
-- Please select --
Less than 1 month
1 month to 1 year
1 year to 3 years
Over 3 years
Pet #3 - Where did you get this pet?
*
Pet #3 - When was this pet last seen by a Veterinarian?
*
-- Please select --
Less than 1 month ago
1 month to 1 year ago
1 year to 3 years ago
Over 3 years ago
Pet #3 - Does this pet have a CURRENT Rabies vaccination?
*
-- Please select --
Yes
No
I don't know
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
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
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
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
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:
*
-- Please select --
My Pet(s)
Myself & my pet(s)
Myself, other family members & my pet(s)
I decline all image release permissions
Upload any additional images we may use for this purpose
*
Max file size: 20MB
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
Upload any additional images we may use for this purpose
*
Max file size: 20MB
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
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)?
*
enter 0 if no adults
How many children reside in your household (0 - 17 years old)?
*
enter 0 if no children
Do you own or rent your residence?
*
-- Please select rent, own or other
Own
Rent
Live with friends/relatives
Living in temporary housing/homeless
How much is your monthly mortgage/rent? (if you live with friends/family, what is your portion of the rent?)
*
enter 0 if you don't pay mortgage or rent
Do you work? If so, what do you make per week?
*
enter n/a if no one works
Do you or any of your dependents receive child support, alimony or retirement and HOW MUCH do they receive per month?
*
enter n/a if no one receives any of these
Do you or any of your dependents receive any government assistance such as SNAP (food stamps), TANF, SSDI (disability), or SSI (social security) and HOW MUCH do they receive per month?
*
enter n/a if no one receives any of these
Upload Proof of Assistance or Income
*
Max file size: 20MB
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
Upload Proof of Assistance or Income
*
Max file size: 20MB
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
Upload Proof of Assistance or Income
*
Max file size: 20MB
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
Upload Proof of Assistance or Income
*
Max file size: 20MB
To upload: 1) click on the Choose File button; 2) find the image or file you want and click on it; 3) click "Open" on bottom right. The selected file name will be listed next to the Choose File button below
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
*
Yes, I'm the owner of all pets
No, I am not the owner of all pets
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.
*
Yes
No
Select YOUR year of birth
*
PLEASE SELECT:
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
ACAP uses this data to apply for grants and does not share individuals' information
PLEASE TYPE YOUR FULL NAME AS IT APPEARS ON YOUR DRIVERS LICENSE, SOCIAL SECURITY CARD, OR STATE ISSUED ID
*
Submit
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