Fill and Sign the 996 Rental Form

P.O. Box 225 Lititz, PA 17543 Fax: (717) 431-5544 Email: info@catsincrisis.org Application Process: Please complete the entire application and don’t leave any fields blank. Incomplete applications will not be considered. You must provide us with an email address to reply to, as all of our correspondence is through email. Please Print clearly and legibly on the application. If possible, please complete on your computer instead of by hand. Typed applications are easier to read than handwritten. In addition to the Financial Grant Application, you must also send the following documentation: Send an email to info@catsincrisis.org explaining your intent to complete our application process and give us a brief explanation of your cat’s medical situation and need. Proof of financial need or explanation of extenuating financial circumstances. Examples include: • recipient of Medicare, or Medicaid • recipient of Social security or disability benefits • recipient of unemployment • recipient of public assistance • other extenuating circumstances considered on a • case by case basis Provide an estimate on veterinary letterhead including: • cat's name, age, proof of neuter/spay • diagnosis • must be one of the following: o Kidney disease o Heart disease o Thyroid disease o Mobility or Neurological Condition • itemized breakdown of costs of treatment needed • prognosis Cats in Crisis Financial Grant Application Name and Age of Applicant: Occupation: Name, Age and Gender of Cat: Address: (street, apt., city, state, zip) Phone Number with Area Code (Home): (Cell) Email address: Name, Address, Phone & Fax Number of Veterinarian: Description of Diagnosis and Medical Treatment Needed Estimated Cost of Treatment: $ Amount You can Contribute: $ Please list other donations you have received and agencies you have contacted: I attest that the information I have provided to Cats in Crisis is accurate and complete. I give my consent for the above-mentioned medical care listed in the veterinary estimate. I understand that Cats in Crisis assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnoses, treatments, products or services. I agree that I have reviewed and understand the Application Process completely and will provide CIC with all of the documentation needed to process my application. I consent to Cats in Crisis’ use of any pictures provided of my pet(s) or its owner(s) as well as a description of the medical care for purposes of promotion and fundraising. I understand any documentation or pictures given to Cats in Crisis cannot be returned. Date: Signature: