Assistance Application

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ACAP is temporarily unable to assist clients who reside outside of Louisa County due to limited funding. For Louisa County residents only you may apply using the form below. For dog spay/neuters or dog procedures for which a veterinarian has diagnosed a condition, you may apply to the Mosby Foundation for assistance: themosbyfoundation.org

* Indicates required field

Name *

First

Last

Applicant should be the owner of the pet(s) seeking assistance

Phone (including area code) *

Mailing Address (including city, state & zip) *

Email *

Have you applied to ACAP for assistance before? *

Yes No

If "yes" did we help, and who did we help? *

What County or City do you live in *

How many Dogs do you have? *

How many Cats do you have? *

Are they ALL spayed/neutered? *

Yes, all of my pets are spayed/neutered No, none of my pets are spayed/neutered Some of my pets are spayed/neutered I'm not sure

If "no" do you agree to spay/neuter your pet(s)? *

Yes No All of my pets are already spayed/neutered

Financial Qualifications

ACAP is a low income based program. Please answer the following questions to see if you qualify: *

Do you work? *

Yes (Full Time) Yes (Part Time) I'm getting unemployment benefits I'm disabled (receiving disability) I'm retired (receiving social security and/or pension) My spouse/partner works, I stay home I do not work

What is your MONTHLY income? Include all household income (parents, spouse, etc) *

How many people live on this income? *

Please provide proof of your income (picture of SNAP/MEDICAID/TANF/SSDI/SSI/Spousal/child support card or letter OR PAYSTUB) *

Max file size: 20MB

Do you own, rent, or live with friends/family? *

Own Rent Live with friends/family

How much rent/mortgage do you pay monthly? *

Tell Us About Your Pets

PET #1 What is this pet's NAME? *

Cat or Dog? *

Cat Dog

How old is your pet? *

How long have you had your pet? Where did he/she come from? *

Is this pet female or male ? *

Female Male

Is this pet spayed (females) or neutered (males)? *

Yes No I'm not sure

What BREED and COLOR is your pet? (EX cats: short or long hair, grey tabby; EX dogs: brown beagle mix) *

What WEIGHT is your pet? (you can estimate) *

Last time seen by a vet? *

Does this pet have a current rabies vaccine? *

Yes No I don't know

What care does this pet need? *

Upload a photo of this pet here (or email it to [email protected] or text it to 540-850-2680) *

Max file size: 20MB

*you can text a photo to our phone @ 540-850-2680

PET #2 What is this pet's NAME? (skip this section if you only have 1 pet) *

Cat or dog? *

Cat Dog

How old is your pet? *

How long have you had your pet? Where did he/she come from? *

Is this pet female or male? *

Female Male

Is this pet spayed (females) or neutered (males)? *

Yes No I'm not sure

What BREED and COLOR is your pet? (EX cats: short or long hair, grey tabby; EX dogs: brown beagle mix) *

What WEIGHT is your pet? (you can estimate) *

Last time seen by a vet? *

Does this pet have a current rabies vaccine? *

Yes No I don't know

What care does this pet need? *

Upload a photo of this pet here (or email it to [email protected] or text it to 540-850-2680) *

Max file size: 20MB

PET #3 What is this pet's NAME? (skip this section if you only have 1 or 2 pets) *

Cat or Dog? *

Cat Dog

How old is your pet? *

How long have you had your pet? Where did he/she come from? *

Is this pet female or male? *

Female Male

Is this pet spayed (females) or neutered (males)? *

Yes No I'm not sure

What BREED and COLOR is your pet? (EX cats: short or long hair, grey tabby; EX dogs: brown beagle mix) *

What WEIGHT is your pet? (you can estimate) *

Last time seen by a vet? *

Does your pet have a current rabies vaccine? *

Yes No I don't know

What care does your pet need? *

Upload a photo of this pet here (or email it to [email protected] or text it to 540-850-2680) *

Max file size: 20MB

Please add any additional information here (personal circumstances, additional pets, etc): *

By submitting this application I agree that: (a) I am the owner of the animal(s) listed, or am authorized to act on behalf of the owner; (b) Unless an exception is made ACAP will approve and arrange veterinary appointments and make payments to clinics; (c) ACAP will approve payment up to a limited grant amount; I am responsible for any amount due above ACAP’s grant amount; (d) ACAP may share applicant and pet information with other sources to include other nonprofits with which ACAP coordinates, veterinary clinics and organizations providing grants; (e) ACAP may post photos and basic information about my pet on social media but will not identify me on such posts; (f) I agree to spay or neuter all cats or dogs in my household to the extent their health makes such procedures safe. ACAP may be able to assist with the costs of these procedures; (g) ACAP’s volunteers are not veterinarians and may not give medical advice. ACAP cannot guarantee that treatment will be successful; (h) I release ACAP from liability related to veterinary treatment. Name (this will serve as my electronic signature and concurrence with the agreement above) *

First

Last

By submitting this application I agree that: I am the owner of the animal(s) listed, or am authorized to act on behalf of the owner. Unless an exception is made ACAP will approve and arrange veterinary appointments and make payments to clinics. ACAP will approve payment up to a limited grant amount; I am responsible for any amount due above ACAP’s grant amount. ACAP may share applicant and pet information with other sources to include other nonprofits with which ACAP coordinates, veterinary clinics and organizations providing grants. ACAP may post photos and basic information about my pet on social media but will not identify me on such posts. I agree to spay or neuter all cats or dogs in my household to the extent their health makes such procedures safe. ACAP may be able to assist with the costs of these procedures. ACAP’s volunteers are not veterinarians and may not give medical advice. ACAP cannot guarantee that treatment will be successful. I release ACAP from liability related to veterinary treatment.

What YEAR were you born? *

Submit

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Financial Qualifications

Tell Us About Your Pets