Medfund Application

Muffie Becks MedFund

320 East Broadway #2B

PO Box 13033

Jackson WY 83002

PH: 307-734-2441 FAX: 866-605-0451

Have you applied for assistance from PAWS of JH before:*

Yes - Medfund
Yes - Another Service from PAWS
No

Pet's Name:*

My pet is a:*

Dog
Cat

and is:*

Male
Female

Breed:*

Age:*

Your Name:*

Physical Address:*

City:*

State:*

ZIP Code:*

Mailing Address:*

City:*

State:*

ZIP Code:*

Telephone Numbers / Home:*

Cell:*

Email:*

PAWS provides financial assistance for an unexpected veterinary expense through the generosity of our MedFund benefactor. We can only help those animals who have been spayed or neutered, and are current on all vaccinations.

Is your pet spayed or neutered?*

Yes
No

Is your pet current on all vaccinations?*

Yes
No

Rabies Vaccination Number:*

Veterinarian:*

Please explain your pet’s injury or illness, and when and how it happened :*

What is the estimated cost of the bill?*

Do you have pet insurance?*

Yes
No

Pet insurance company (optional):

Have you been a Wyoming/Idaho resident for at least 1 year.*

Yes
No

Upload current and past (1+ years) proof of residency

Drop files here or

Max. file size: 64 MB.

drivers license, utility bill, lease or mortgage

MedFund assistance is for emergency or unexpected veterinary care. PAWS cannot help with routine care, vaccinations or elective procedures. PAWS reserves the right to review financial information of each applicant to avoid any fraud or misuse of our MedFund. Upon approval, PAWS will contribute up to $350 towards a veterinary bill. Payments will be made only to local veterinarians. No payments will be made to individuals.

This is a single-use program meant for veterinary emergencies or injuries. You can apply for MedFund assistance only once and you must apply before or during treatment. Veterinarians and PAWS will not reimburse you for a bill that you have already paid. It is your responsibility to apply at the time of funding need. Any remaining balance after PAWS has granted funding is your financial responsibility.

With your application, PAWS requires one of the following as proof of residency – lease, mortgage stub, paycheck, utility bill or a cell phone bill – that shows the address that you listed above. We require a copy from one year ago and one showing the current month.

If you are approved, our benefactor likes to know that the gift is being put to good use. We require a thank-you note and a photo of your pet. Please send it to us at PAWS. Your signature confirms that you understand the terms of our gift.

Check the box below to confirm that you understand the terms of our gift. *

Yes, I understand the terms of this gift:

Yes

Anything else you would like us to know:

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