Emergency Assistance (for pet owners) is sponsored by Finley Fort Foundation, LLC. The Finley Fort Foundation provides financial assistance to pet owners in Hawaii who need emergency veterinary care. They aim to ensure no pet owner has to say goodbye due to inability to pay for treatment.

Medical Funds Assistance Application Finley Fort Foundation Emergency Funds Application Application for Veterinary Medical Financial Assistance First Name (Person) Last Name Please enter a valid phone number. Format: (000) 000-0000. Use N/A if no IG to tag in posts Browse Files Drag and drop files here To be used for Finley Fort Foundation marketing purposes I/We are applying for assistance for an upcoming medical service.

* Yes - this is for an upcoming service No - no this is for a reimbursement Veterinary Hospital or Clinic Name * Estimate or Invoice Amount of Treatment * Does your Hospital or Clinic accept payment by: * Secure payment link (via email or text) Mail in check - we can mail check after service are confirmed and invoiced Upload Medical Estimate or Invoice * Browse Files Drag and drop files here Medical issues, Story, Reason for Assistance, Additional Info (Age, breed, etc.).

Used for marketing updates. Do you have Pet Insurance * If you have Pet Insurance, what is the estimated expected reimbursement?

Estimated $ or % to be refunded by Insurance Did you apply for any other assistance (ex: CareCredit) * Full Time Part Time Other Gross Annual Household Income (estimated before taxes) * Less than $25,000 $25,000 to $49,000 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 to $199,999 $200,000 or more How will you (how did you) pay for the procedure(s).

Check all that apply * Cash/Check - out of pocked Care Credit Care Credit Insurance Reimbursement Other How did you hear about Finley Fort Foundation? * Vet/Clinic Referral Friends or Family Website/Online Search News Magazine Other Finley Fort Foundation (FFF) cannot guarantee full medical cost coverage, and not all applications will be approved. The majority of approved awards cover a partial portion of the total treatment cost.

FFF assistance is limited to upcoming or in-progress veterinary treatments that have not yet been fully paid. Applications submitted for treatments already completed and paid in full, or to reimburse or pay off existing credit card balances, CareCredit accounts, loans, or any other financial obligations, are not eligible.

If approved, FFF will pledge the awarded amount and pay the veterinary hospital or clinic directly via mailed check or secure electronic payment. Please verify with your clinic that this is acceptable prior to submitting your application. FFF does not process payments over the phone or in person, and does not issue payments directly to individuals.

Any unused portion of approved funds must be returned to FFF promptly. If the applicant has pet insurance and receives a reimbursement for the same treatment funded by FFF, the lesser of the two amounts must be returned to FFF so that combined payments do not exceed the applicant's actual out-of-pocket cost of treatment. The recipient agrees to provide any documentation needed for FFF accounting or tax purposes.

The medical provider must be able to supply a receipt or invoice directly to FFF upon request. We kindly ask for your support in raising awareness of FFF's mission and promoting fundraising efforts so FFF can help more of Hawaii's pets receive the care they need.

Misrepresentation of any information in this application, including failure to disclose insurance reimbursements or failure to return unused funds, may result in disqualification from current and future FFF programs. I, {recipientsName}, agree to the Terms & Conditions of Finley Fort Foundation *