Senior Pet Connection Assistance Application Senior Pet Connection is a program of the Humane Society of Pinellas. SPC allows seniors to apply for pet food assistance on an indefinite, monthly basis. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Information Your Phone: Your Email: Emergency Contact Information Emergency Contact Phone: Emergency Contact Email Driver's License # (or state issued ID)* Where do you live?* House Apartment/Condo Mobile Home Assisted Living How many adults live in your home? Is anyone in your home a veteran? Yes No What type of assistance are you requesting? Check all that apply.* Pet Food Cat Litter Tell us about your pet (you can request help for up to 3 pets) Name Provide information on your pet. If you are requesting assistance for more than one pet please list each pet individually in the provide sections.Type of Pet*DogCatBirdSelect only oneBreed If you are unsure of your pet's breed, describe as mixed breed for dogs. For cats please list as domestic short or long haired.Pet Gender Male Female Pet Age (approx)* Weight Enter your pet's weight (approx)What Type of Food Does Your Pet Eat?* Wet food Dry food Both Check all that apply.How long have you owned your pet? Spayed/Neutered? Yes No Don't Know Up to date on vaccines? Yes No Don't Know Tell us about your 2nd pet (you can request help for up to 3 pets) Name Provide information on your pet. If you are requesting assistance for more than one pet please list each pet individually in the provide sections.Type of Pet*DogCatBirdSelect only oneBreed If you are unsure of your pet's breed, describe as mixed breed for dogs. For cats please list as domestic short or long haired.Pet Age (approx)* Pet Gender Male Female Weight Enter your pet's weight (approx)What Type of Food Doest Your Pet Eat?* Wet food Dry food Both Check all that applies.How long have you owned your pet? Up to date on vaccines? Yes No Don't Know Spayed/Neutered? Yes No Don't Know Tell us about your 3rd pet (you can request help for up to 3 pets) Name Provide information on your pet. If you are requesting assistance for more than one pet please list each pet individually in the provide sections.Type of Pet*DogCatBirdSelect only oneBreed If you are unsure of your pet's breed, describe as mixed breed for dogs. For cats please list as domestic short or long haired.Pet Gender Male Female Pet Age (approx)* Weight Enter your pet's weight (approx)What Type of Food Does Your Pet Eat?* Wet food Dry food Both Check all that applies.How long have you owned your pet? Spayed/Neutered? Yes No Don't Know Up to date on vaccines? Yes No Don't Know INCOME QUALIFICATION SECTION. What is the total monthly income for all residents in your household?* Proof of income, e.g., copy of Social Security benefits statement. SNAP card, etc. is required with this application to process your request for assistance. Be sure to black out your Social Security Number before sharing your documents with us.How did you hear about the Senior Pet Connection? If there anything else you would like us to know to help us better understand your needs?Consent*You may submit your proof of income in any of the following ways: Email to: [email protected] Mail to: Humane Society of Pinellas ATTN: SPC 3040 State Road 590, Clearwater, FL 33759. Fax: (727) 793-0549 I certify that information I have provided is true and complete. I understand that false information may be grounds for immediate dismissal of this application. I authorize HSP to verify any or all of the information listed above.Name* First and Last Name: Date Entering your name and date serves as your signature consent on this application.