Application for Assistance
*** MAKE SURE that your email will not mark as spam or junk any email from "@smartsheet.com " This is how we will respond to your application. Also check your spam folder after applying. We will email you within a few days, if you miss our email we won't be able to continue with your application.
* We need: last tax year 1040, last month bank statement, and a clinic invoice. Upload from your computer at the end of the form or fax to 914-206-4301.
Your application will be on HOLD for 1 week if you have not sent all documents. After 1 week, your application will be withdrawn. If you cannot upload or fax, tell your bank or clinic to fax to us at 914-206-4301.
Also send any documents that show financial distress (social services statements, disability statements, unemployment statements, bankruptcy letters, foreclosure notices, etc.).
Type dog's first name and your last name.
Your full name
(Must be the owner of the dog)
Name of Spouse or live-in boy/girl friend
If you fill in a name, explain his/her relationship to you and to your dog.
If none type "none."
Your date of birth
Your email address
Your primary phone number
Secondary phone number
Leave blank if none. FORMAT xxx-xxx-xxxx. Application will be rejected if it is not in this format.
Use two-letter state code, like NY or CA or MN
Names/Ages of other adults living in your home
Don't include yourself, or your partner/spouse.
If none type "none." For other adults living in home, type each NAME, AGE and RELATIONSHIP to you.
Who pays household expenses?
Are you currently working?
Your occupation at current or most recent job
Job title and company name. If you are NOT working now, type info for your last job no matter how long ago it was.
** If you or spouse has been in the Military, say so here.
Spouse or live-in boy/girl friend employed?
Their occupation at current or most recent job
Any DEPENDENTS on your tax return?
If yes, type names and ages
Names/ages of other pets in your home
Names and ages
If any adult in home doesn't file taxes, who & why
Total household income last year
Total EXPENSES last year
BREAK DOWN - Include mortgage/rent, utilities, property taxes, insurance, car payments, phone/internet/cable, loans, etc. Only scheduled payments, do not include food, gasoline, movies etc.
Any change in income/expenses from last year?
If yes, explain the change.
Do you own your home?
Do you receive social services?
Do you receive any assistance from social services? )If yes, Upload statements at end of this form.)
If yes, which social services?
If any adult in home has a DISABILITY, what is it?
Say yes only if you receive Disability payments. Say specifically what the disability is. You must send us the disability statement or letter with your financial information (below).
Explain why you are in a financial situation where you need our help.
ABOUT YOUR DOG
Weight in pounds
If not spayed/neutered, why not?
Is this a working dog?
If yes, then you must attach certificate showing your dog's status as a working dog. Do not send letter from therapist. "Emotional assistance" is not included unless dog was agency trained.
Not a working dog
Military working dog
Registered assistance dog
Other health issues or previous cancer
YOUR DOG'S CANCER TREATMENT
Name of clinic where this dog has annual check ups
You must give this clinic permission to speak to Magic Bullet Fund about your dog. If we call and they have not received your permission, your application will be withdrawn.
Phone number regular vet
Type in format xxx-xxx-xxxx. Application will be rejected if it is not in this format.
Name of vet who will give cancer treatment
Before you apply, you have seen this vet for a consult, and you have given this vet permission to speak to Magic Bullet Fund about your dog. If we call and they have not received your permission, your application will be withdrawn.
NAME OF CLINIC
Clinic telephone number
Type in format xxx-xxx-xxxx. Application will be rejected if it is not in this format.
Clinic that provided 2nd opinion (plan + costs)
If any, type name/phone of clinic that provided 2nd opinion with treatment plan and cost estimate. (Not just a referral)
If you have not had a 2nd opinion, type NONE.
Type of Cancer
If your dog has a tumor, also give the LOCATION of the tumor.
Date of Diagnosis
Click calendar - approximate if necessary
Treatment given up to now
Type of treatment you are seeking help for
Magic Bullet Fund provides assistance for only one type of treatment. We no longer provide assistance for radiation treatments.
Fee estimate for treatment
Give amount the vet estimated. Also describe your understanding of what treatment will be given.
How much are you able to pay?
If surgery, type a flat amount. If chemo, type the amount you can pay PER WEEK. Do not include funds you are receiving from other organizations.
A FEW MORE FINAL QUESTIONS
Do you have a medical insurance policy for your dog?
If yes, type company and policy number
Also provide any info you have about their coverage for your dog's cancer treatment.
Other organizations you have applied to
Type name of organization AND their responses. Include Care Credit if you applied. Include GoFundMe or any fundraising efforts WITH link to campaign.
You should also apply to the orgs on this page
If accepted will you fundraise for your dog?
The fund would raise most of the funds, but we need your help. Would help us raise donations by asking for donations via email (we provide a sample email) and posts on Facebook and at online (or real life) groups?
What makes your dog special?
Describe how your relationship with this dog is special. How will you feel if you receive assistance?
Anything else we should know?
Anything else you want us to know about you and/or your dog?
Willing to volunteer?
Are you willing to take a volunteer job for Magic Bullet Fund?
IF YES - after you fill in this form, fill in volunteer form on bottom of ANY page on our website (
Yes only if my dog receives assistance
Yes in any case
Do you agree to the following Terms of Assistance?
1. If accepted, MBF will start your dog's fundraising campaign with a gift from our General Fund. You will actively try to raise donations to MBF for your dog. You will write an email to friends and family asking for donations for your dog, post actively on your Facebook page etc. You will post regularly on the MBF Page at Facebook while your dog is in fundraising.
2. Donations for your dog will be held on reserve for your dog's treatment fees. If there is a 6-month period where no funds are used, the remaining contents of the campaign will be reallocated to the General Fund to help us help other dogs.
3. MBF funds are never used for diagnostic tests, past due fees, routine health care, conditions other than cancer, palliative care, euthanasia, burial or cremation.
4. Funds raised for a dog do NOT belong to the recipient or their dog. When a dog no longer needs treatment, when treatment is not successful, when a recipient doesn't comply with MBF policies, or when MBF has raised more funding than needed, funds on reserve for that dog are redistributed to the General Fund and used to help other MBF dogs.
5. CHEMO: From your dog's campaign, MBF will contribute a set amount for each chemo treatment. As donations come in for your dog, the amount MBF contributes per treatment increases.
SURGERY: The campaign will be open for 30 days, or until 5pm the day before your dog's surgery. When we have raised enough so you can pay the balance, you schedule surgery.
6. You may not donate into your own dog's campaign. You may not donate for any dog in the fund or to the General Fund until your dog's fundraising campaign is finished.
7. You will inform MBF about any other organizations that contribute to your dog's cancer treatment fees.
8. You grant MBF permission to discretely share the information you send us with other organizations, for the purpose of raising additional funds for your dog's treatment.
9. You grant MBF permission to print or post all photos / text that you send us or that you post on the MBF Facebook page, to promote MBF.
10. * TV and NEWSPAPER - If MBF arranges a media story (TV, newspaper etc.) about your dog and the fund, you will be available for interviews.
11. Magic Bullet Fund is not in any way responsible for the results of your dog’s treatment, the quality of your dog’s medical treatment or any treatment side effects.
Send us documents
If we do not receive the following THREE files from you within a week, your application will be withdrawn. If there is a reason you cannot send any of these THREE files, explain here:
UPLOADS - please send PDF files (not JPG files)
1) TAXES - The 1040 from your most recently filed taxes. (Cross out social security numbers). If you have not filed taxes, send instead your disability letter/stub, SSI letter/stub, or whatever you have. If someone else pays the household bills, send their 1040 as well.
2) LAST MONTH'S BANK STATEMENT - If you cannot send, ask bank to fax to 914-206-4301. Do not cross out bank account numbers! Anyone you write a check to has them, they are not private. And if someone else pays household expenses, send theirs as well.
3) CLINIC ESTIMATE - Send the clinic's estimate for treatment (the clinic where your dog will have cancer treatment). If you cannot send, ask clinic to fax to 914-206-4301.
If your dog is a working dog, upload certificate or other proof that he is a working dog.
If you have a bankruptcy or foreclosure letter, send that too.
Just click UPLOAD again to upload additional documents.
** If you cannot upload documents:
Email documents to us at firstname.lastname@example.org
or Fax to 914-206-4301.
Or you can ask your bank / clinic / accountant to send us the requested documents at email and fax number above.
** Apply to other organizations
Please apply to other organizations as well. You can find a list here:
Send me a copy of my responses
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