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Veterinary Care Assistance Application

    If you received public assistance, please provide a copy of the card or qualifying letter that proves a member of your household participates in one of the following programs to qualify: Adult Medicaid, Child Medicaid, Food Stamps, Social Security/Social Security Disability. If you do not receive public assistance or would like to qualify by income, please provide a copy of your best proof of income (for example, copies of W-2 forms, check stubs, SSI benefits letters, etc.) for each adult in your household. You may also choose to provide eviction notice or verification of unemployment. Important note about privacy: The information you provide will be used only for confirmation of your eligibility and will not be used for any other purposes. For additional protection of your private information, please mark through the Social Security numbers on all copies of documents.
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