The BooTiki Fund Grant Application

The following is the BooTiki Application for grant approval.

Please email us at BooTikiFund@comcast.net with any questions or if this is an emergency case.

Thank you for your interest in the BooTiki Fund

Basic criteria your pet must meet:

Applicant must have applied for and been denied Care Credit and Wells Fargo Health Advantage Credit Card. Please see information below for details.
Have had an exam by a vet in the past month.
Be in good standing with your current veterinarian.
Be current on all vaccinations.
Be owned by the applicant (we do not fund foster pets or pets that have not been released by pet rescues).
Have a diagnosis and plan for treatment from your vet.
Have a reasonable chance for full recovery stated by the vet making the diagnosis.
Have a covered diagnosis (For example, we do not fund cancer related treatment or routine care like dental cleanings and vaccines).
Have an estimate for care from the vet.
Live within our service area.

Please note:

Missing information may lead to your application being denied without further process. Incomplete applications will not be evaluated.

Receipt of a completed application does not guarantee grant approval. Final approval is determined by votes cast from approved BooTiki Fund board members.

We require the following financial information to evaluate the application:

Applicant must have applied for and been denied Care Credit and Wells Fargo Health Advantage Credit Card to receive grant funding. Please see information below for details about these financing programs.
A Copy of income for all members of the household. Examples include pay stubs, Social Security or Disability payments, pensions, annuities, IRA or 401k payments. Include whatever income you include in your federal income taxes. (We do not want your actual income tax documents.)
If anyone in the household is over age 59.5, we require disclosure of IRA, Roth IRAs or 401K balances.

Care Credit and Wells Fargo Health Advantage Credit Card:

The denial letter or email from any pet specific credit card system like Care Credit or Wells Fargo’s specialty credit card.

https://www.carecredit.com/apply/

https://retailservices.wellsfargo.com/wfha_veterinarians.html

Veterinary Information about your pet we will need to evaluate the application:

A written plan from the vet that will treat the illness and the cost estimate for the treatment (attach to application)

PLEASE NOTE: Missing information will result in a delay or rejection of the application. We try to process applications within 5 business days. Should this be an emergency case please inform the director at submission and we will do our best to process the application within 24 hours.

Questions?

Email for questions and application submission: BooTikiFund@comcast.net

BooTiki Grant Funding Application

Date of Application*
Date of Application
MM slash DD slash YYYY
Name of applicant requesting funding*
Name of applicant requesting funding
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Applicant Email address*
Applicant Email address
Applicant cell phone number*
Applicant cell phone number
Number of People in Household including children*
Number of People in Household including children
Number of people earning a wage or have income in a household*
Number of people earning a wage or have income in a household
Dollar amount of grant requested*
Dollar amount of grant requested
Total household income?*
Total household income?
Amount of household savings not in a retirement account.*
Amount of household savings not in a retirement account.
Total amount of savings in all retirements funds. (Only for applicants over the age of 59.5 years old)*
Total amount of savings in all retirements funds.
Have you applied for Care Credit?*
Have you applied for Care Credit?
- Yes
- No
Date applied for CareCredit.
Date applied for CareCredit.
MM slash DD slash YYYY
Were you approved or denied Care Credit?*
Were you approved or denied Care Credit?
- Approved
- Denied
If approved for Care Credit, please indicate approved amount.
If approved for Care Credit, please indicate approved amount.
Current balance of Care Credit account (if applicable).
Current balance of Care Credit account (if applicable).
Have you applied for a Wells Fargo Health Advantage Credit Card?*
Have you applied for a Wells Fargo Health Advantage Credit Card?
- Yes
- No
Date applied for Wells Fargo Health Advantage credit card.
Date applied for Wells Fargo Health Advantage credit card.
MM slash DD slash YYYY
Were you approved or denied a Wells Fargo Health Advantage credit card?*
Were you approved or denied a Wells Fargo Health Advantage credit card?
- Yes
- No
If approved for Wells Fargo Health Advantage, please indicate approved amount.
If approved for Wells Fargo Health Advantage, please indicate approved amount.
Current balance of Wells Fargo Health Advantage account (if applicable).
Current balance of Wells Fargo Health Advantage account (if applicable).
Please describe all attempts you have made to raise funds for the issue you are seeming grant funding for.*
Please describe all attempts you have made to raise funds for the issue you are seeming grant funding for.
Name of pet*
Name of pet
First
Species / type of pet*
Species / type of pet
Breed*
Breed
Male intact/Female intact/Spayed/Neutered?*
Male intact/Female intact/Spayed/Neutered?
Color(s)*
Color(s)
Referring veterinarian*
Referring veterinarian
First Last
Name of veterinary practice of your referring veterinarian*
Name of veterinary practice of your referring veterinarian
Referring veterinarian's phone number.*
Referring Hospital Address*
Referring Hospital Address

Street Address Address Line 2 City/Town State ZIP code
Diagnosis*
Diagnosis
Referring veterinarian's evaluation of likely outcome if recommended treatment is followed.*
Referring veterinarian's evaluation of likely outcome if recommended treatment is followed.
Please attach any documents to support your application here.
Please attach any documents to support your application here.
Drop files here or

Max. file size: 128 MB.
CAPTCHA