The Lucy Fund was established to assist people who cannot afford needed veterinary expenses, and who without financial assistance would have to surrender their beloved pets to a shelter. The fund was named for a very special little dog who recovered from a life-threatening injury because a caring community stepped in to cover her medical expenses. One hundred percent of all tax-deductible donations are used to pay for urgent medical care for pets of people who cannot afford to have their pets treated.
APPLICANT INFORMATION

Question Title

* 1. Name (First and Last)

Question Title

* 2. Address

Question Title

* 3. City, State and Zip code

Question Title

* 4. Email address

Question Title

* 5. Cell Phone

Question Title

* 6. Home Phone

PET INFORMATION

Question Title

* 7. Pet's Name

Question Title

* 8. Breed?

Question Title

* 9. Cat, Dog or list other

Question Title

* 10. Color?

Question Title

* 11. Age?

Question Title

* 12. Male or Female?

Question Title

* 13. Spayed/Neuter?

ABOUT THE ANIMAL'S INJURY OR ILLNESS

Question Title

* 14. Date of Last Vaccinations?

Question Title

* 15. Does This Case Involve Animal Cruelty Charges?

Question Title

* 16. If Yes, Please Explain.

Question Title

* 17. Date of Injury or Illness?

Question Title

* 18. Describe Injury or Illness.

Question Title

* 19. If your pet has been seen by a veterinarian, please describe the medical treatment needed.

Question Title

* 20. Amount You Can Contribute?

Question Title

* 21. Estimated Cost of Medical Treatment?

VETERINARY INFORMATION

Question Title

* 22. Veterinarian's Name?

Question Title

* 23. Clinic or Hospital Name?

Question Title

* 24. Clinic Address:

Question Title

* 25. City, State and Zip Code:

Question Title

* 26. Phone Number:

Question Title

* 27. Fax Number:

Question Title

* 28. Email:

Please email copies of any applicable veterinary records to judiburnett@gmail.com

Question Title

* 29. ADDITIONAL REQUIREMENTS
I understand that a photo of my pet is required to accompany this application and may be used in media materials for the express purpose of future fundraising. Photos of your pet should be emailed to judiburnett@gmail.com.

Question Title

* 30. I understand that you will be following up on my pet's condition and recovery, and I agree to these follow-up interviews.

Question Title

* 31. I understand you may also request pictures of my pet with family members following his/her recovery and I agree to provide these.

APPLICANT FINANCIAL INFORMATION

Please demonstrate financial need by providing proof of enrollment of one of the following. Texas Medicaid Texas Temporary Assistance for Needy Families (TANF) Texas Supplemental Nutrition Assistance Program (SNAP) Texas WIC Program for Women, Infants & Children Texas Employment Insurance Social Security SSI Disability
Please email your proof of enrollment in one of the above programs below to judiburnett@gmail.com. If you do not have proof of enrollment, please provide a pay stub or Form 1040 showing your income meets WIC income levels.

Please email your proof of enrollment in one of the above programs below to judiburnett@gmail.com. If you do not have proof of enrollment, please provide a pay stub or Form 1040 showing your income meets WIC income levels.

Question Title

* 32. BY TYPING MY NAME BELOW AND SUBMITTING THIS APPLICATION, I HEREBY AUTHORIZE THE VERIFICATION OF THE INFORMATION PROVIDED ON THIS FORM.
Signature of Applicant (Type your name)

SIGNATURES

Question Title

* 33. Date:

T