Financial Aid Form

Please do NOT submit this application if you do not meet the following qualifications:

  1. Applicants must live in Leadville or Lake County.
  2. Single applicants must earn less than $45,000 gross/year or married/partnered applicants must earn
    less than $70,000 gross/year. Gross income includes ALL sources of income: business,
    unemployment, disability or investments before taxes or expenses, and you must be willing provide
    information on your net worth upon request during PPL’s review of your application. PPL reserves the
    right to deny assistance if it is determined that the reported net worth varies greatly from additional
    information provided.

Financial Information & Verification of Employment

If you live with a spouse or partner, both incomes must be submitted.

Pet Information


Please enter your estimate amount.
You MUST ALSO provide a written estimate from your vet.
Click or drag a file to this area to upload.
You must submit an estimate from your Vet. If you cannot upload an estimate, you may drop it off to Chris at:
Rocky Mountain General Counsel
607 Harrison Ave in Leadville
There is a mail slot for after hours drop-offs.

TERMS AND CONDITIONS

ACKNOWLEDGMENT, RELEASE AND HOLD HARMLESS AGREEMENT:
By submitting this form, I/We hereby affirm that the information provided is true and correct to the best of my/our knowledge, information and belief. I/We authorized PPL to contact my/our employer(s) to verify the information listed above. If approved as a recipient of any assistance funds from PPL, I/We fully agree to save, indemnify and hold harmless Planned Pethood Assistance, Inc. t/a Planned Pethood Leadville from and against any and all claims, demands, suits, actions, fees and costs incurred for loss or liability of any kind, arising directly or indirectly out of this application or performance of medical care, surgery or post-surgical care of the animal using funds provided by PPL. I/We consent to PPL contacting me/us by telephone or email.

MEDICAL RELEASE:
By submitting this form, I/We hereby grant permission to PPL to exchange medical information with any veterinarians involved with providing care for my/our pet in order to determine my/our eligibility for and provision of assistance.

IMPORTANT NOTES TO APPLICANT(S): Your application will be reviewed by PPL usually within 48 hours after it is received and you will be notified of any request for additional information and/or the funding decision by e-mail or phone. PPL cannot guarantee expedited review of emergency applications. If your pet has an emergency situation, you are responsible to get them the necessary care and then you may submit an application for financial assistance. All applications for emergency services must be submitted within two (2) weeks of your pet’s medical services being completed or from the date of the estimate from the veterinarian for such services.

Please keep in mind that PPL is an all-volunteer non-profit organization. Members of the Board of Directors review applications received in their spare time, so please be patient and help expedite the application process by promptly submitting all requested information and regularly checking your email or voice mail for messages from PPL. PPL can only pay your veterinary services provider (and not you or other individuals), and such payment will only be made after PPL’s Treasurer has been invoiced by that provider. PPL may only be able to cover a portion of any invoice, and you remain responsible for any other unpaid balances. Veterinary service providers outside of Lake County may be used by applicants after PPL’s approval of an application, but they must be advised in advance of PPL’s payment process and billing procedure and provide consent to such arrangements. You must also provide contact information for any provider used, including their name, phone number and email address so that PPL can contact them directly to confirm the services to be provided and discuss payment arrangements. If you have already paid your bill, it is your responsibility to work out the details with your veterinarian to credit your account.

We hope that Planned Pethood Leadville will be able to provide assistance to you and your pet!