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.
* You must send last tax year 1040, last month bank statement, car registration 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 if you have not sent all documents. We MUST receive documents within a week. If we do not, your application will be withdrawn.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 documents that show financial distress (social services statements, disability statements, unemployment statements, bankruptcy letters, foreclosure notices, etc.).
We have an unusually high number of applications right now. The Case Managers are working very hard to pass them through the review board but there will be a longer-than-usual wait before you hear back from us.
Please apply to other organizations as well as to the Magic Bullet Fund - you can find a list here
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."
Names/Ages of other adults living in your home
If none type "none." If other adults in home, type their NAME, AGE and RELATIONSHIP to you. For each.
Your email address
Your date of birth
FORMAT - xx/xx/xx
Who pays household expenses?
Your primary phone number
Secondary phone number
Leave blank if none. FORMAT xxx-xxx-xxxx
Use two-letter state code, like NY or CA or MN
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 have 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
Itemize. Include property taxes, medical insurance, car payments/insurance, 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.
Name of vet who will give cancer treatment
You must have seen this vet for a consult, and you must 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
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
Do you have a medical insurance policy for this dog?
If yes, type company and policy number
Also provide any info you have about their coverage for your dog's cancer treatment.
Weight in pounds
If not spayed/neutered, why not?
Is this a working dog?
If yes, then with your financials you must attach certificate showing your dog's status as a working dog. Do not send letter from therapist.
Not a working dog
Military working dog
Therapy dog (attach certificate)
Other health issues or previous cancer
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.
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.
If accepted are you prepared to fundraise?
The fund will raise most of the money needed. But you would be asked to also email everyone you know, asking for donations (we provide a sample email). And post on your Facebook or online groups asking for donations.
What makes your dog special?
Describe how your relationship with this dog is special
Anything else we should know?
Anything else you want us to know about you and/or your dog?
How will you feel if you receive this assistance?
Willing to volunteer?
While a dog in in treatment, the owner cannot volunteer. Are you willing to volunteer and help run this fund, after your dog finishes treatment? (Will not effect our review of your application.) IF YES - after you fill in this form, fill in volunteer form on bottom of our website page.
Yes only if my dog receives assistance
Yes in any case
Do you agree to the following Terms of Assistance?
1. MBF will start your dog's fundraising campaign with a gift from our General Fund. Then you and the Fund will work to raise donations. You must raise donations in order to use the gift from the General Fund.
2. You will run an active fundraising campaign to raise donations to MBF for your dog. You will write an email to your friends and family asking for donations for your dog.
3. You will post on the MBF Page at Facebook while your dog is in fundraising.
4. Donations for your dog will be held on reserve for your dog's treatment fees.
5. If there are funds remaining in your campaign and there is a 6-month period where no funds are used, the remaining contents of the campaign will be reallocated to the General Fund and then used to help us help more dogs.
6. MBF funds are never used to pay for diagnostic tests, past due fees, routine health care, conditions other than cancer, palliative care, euthanasia, burial or cremation.
7. 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 in need of funding.
8. For dogs in chemotherapy: From your dog's campaign, MBF will contribute a set amount for each chemo treatment. The campaign will be active for 30 days. As donations are made to MBF for your dog, the amount MBF contributes per treatment increases.
9. For dogs having surgery: The campaign will be active until 5pm the day before your dog's surgery or for 30 days. Your dog's reserve will be available for payment to your clinic for your dog's surgery fees upon invoice.
10. You may not donate into your own dog's fundraising campaign. You may not donate for any dog in the fund or to the General Fund until your dog's fundraising campaign is finished.
11. You will inform MBF about any other organizations that contribute to your dog's cancer treatment fees.
12. You grant MBF your express permission to discriminately and discretely share the information you send us with other organizations, for the purpose of raising additional funds for your dog's treatment.
13. You grant MBF your permission to print or post all photos / text that you send us or that you post on the MBF Facebook page, to promote MBF.
14. If MBF arranges a media story (TV, newspaper etc.) about your dog and the assistance you received from MBF. You will be available for interviews and photos with the producer, journalist or editor.
15. 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.
Why you cannot send 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.)
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.)
3) CLINIC INVOICE - Send the invoice from your last visit to the clinic where your dog will have cancer treatment. ** If you cannot send, ask clinic to fax to 914-206-4301.
4) CAR REGISTRATION in your name for the vehicle you will use to take your dog to treatments.
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.
Click UPLOAD again to upload additional documents.
If you cannot upload
Email documents to us at email@example.com
or Fax to 914-206-4301.
Or you can ask your bank or clinic or accountant to send us the requested documents. Use the email and fax number above.
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