* Website Hosting Donated By * Kevys.net Hosting WWW.kevys.net If you would rather download and print the application, you can find it here: DOWNLOAD PDF APPLICATION Lake Area Pet Pantry Application Please read all Qualifications For Assistance, Rules & Regulations, Income Guidelines and Notes before completing the application Thanks - LAPP Board ***QUALIFICATIONS FOR ASSISTANCE*** To qualify for the pantry program, those seeking supplies &/or vouchers need to be approved with a one-time application prior to receiving their first monthly distribution. Approvals for receiving supplies/vouchers will be based on the household income guidelines listed below and the hardship statement found in the application. IF YOUR FAMILY EXCEEDS THE INCOME GUIDELINES, PLEASE LET US KNOW YOUR CIRCUMSTANCES. WE REVEIW EACH SITUATION ON A CASE BY CASE BASIS. We understand that unexpected emergencies do arise, and temporary help may be needed. -Proof of income can be a card or award letter from a government assistance program or Social Security, pay stub, tax return, or unemployment stub. -Please bring a photo ID at time of pick-up. ***INCOME GUIDELINES*** - 1 Person/Household. $16,000/year or less - 2 Person/Household. $25,000/year or less - 3 Person/Household. $28,000/year or less - 4 Person/Household. $34,000/year or less - 5-6 Person/Household. $38,000-$40,000/year or less ***RULES & REGULATIONS*** -I understand that this program is for companion animals only. -I understand that LAPP is a nonprofit group run by volunteers and relies upon donations. -I understand supplies will be provided for up to 3 pets and this program is meant to supplement my food sup- ply. Please note: If LAPP has extra, we will always try to provide for additional pets in the household. -I understand supplies for this program are donated from various sources, therefore the LAPP cannot guarantee the quality or quantity. -I understand supplies are limited and the LAPP’s goal is to keep companion pets with their families and out of shelters; therefore, this program is NOT for individual rescuers or group rescuers. -I agree to NOT add any new pets to my household. This means if a current pet is no longer with you ... you many NOT replace it with a new pet. Our view is, if you take on a new pet, you feel you can afford to feed it and you will be removed from the program. -I understand that my financial qualifications will be reassessed every 3 months or as the LAPP deems neces- sary. -I understand that is a 12 month assistance program at which time benefits will be terminated for a period of six months, at which time you can reapply for another 6 months' worth of benefits, not to exceed 18 months total. When completing the application, you will need to provide financial verification (i.e. pay stubs, social security award letter, tax returns, etc.) All financial documentation will be shredded following review by the LAPP board. -I agree that if my pets are not neutered (fixed), I must have them neutered. LAPP has vouchers for neutering and rabies vaccinations when funds are available. -I agree that my pet(s) are not used for breeding, gambling or fighting. ***NOTES*** 1.) Pet supplies/vouchers are provided on a first come, first serve basis. We are a supplemental resource that depends upon donations and volunteers; therefore we cannot guarantee the amount or kind of supplies you will receive. 2.) Completion of the application is not a guarantee of acceptance. All applications are reviewed and accepted at the discretion of the LAPP board. We reserve the right to refuse or discontinue service to anyone under any circumstance. 3.) Failure to comply with any of the requirements or statements within this application or the abuse of volunteers or the pantry system will result in immediate termination of assistance. 4.) LAPP, LAPP Board Members, LAPP Volunteers or the LAPP donors cannot be held responsible for injury at LAPP distribution or collection sites. 5.) We accept donations of all kinds of pet products. By accepting products and/or services from the Pantry, the recipient, all household members, their friends, and family agree not to hold the LAPP, volunteers, and bene- factors legally liable in the unfortunate event the recipient’s pet(s) becomes ill or the food upsets the pet’s stomach. By submitting this application, I agree that all information provided is true to the best of my knowledge. I also agree to the LAPP rules and regulations. PERSONAL INFORMATION Applicant Name First Name: Middle Name: Last Name: Applicant Must Be A Resident Of South Dakota Street Address (Required): City (Required): State (Required): Zip Code (Required): Your Email (required) Your Phone (required) I Am Applying For: Product AssistanceSpay/Neuter(Voucher)Rabies Voucher Household Members Section ***Please List ALL Household Members Below And Their Relationship To You*** Household Member 1 Name: Relationship: Household Member 2 Name: Relationship: Household Member 3 Name: Relationship: Household Member 4 Name: Relationship: Household Member 5 Name: Relationship: Household Member 6 Name: Relationship: *Marital/Financial Section* Current Marital status: SingleMarriedDivorcedSeparatedWidowed Number of children in household: Do You Receive Monthly Child Support Payments? YesNo If "Yes" --> Amount: Do You Make Monthly Child Support Payments? YesNo If "Yes" --> Amount: Current Job Status? Full TimePart TimeUnemployed Job/Employer 1: Monthly Income: Job/Employer 2: Monthly Income: Is there ANYONE else living in your household that helps with bills? YesNo Total Monthly Income For ALL Employed House Members: Do you Own or Rent? OwnRent Monthly Housing Payment: Financial Asset Information ***Please enter the current balance of each account and than enter the total of all accounts into the Total Box*** Checking Accounts: Savings Accounts: IRA Accounts: Cash On Hand: Total Combined Assets: Pet owners must be receiving one of the following forms of assistance. (If owner is not, there is a section farther on for owner to explain financial hardship.) Please enter the amount that you are receiving for any of the following assistance programs. Unemployment --> Amount: Social Security --> Amount: Disability --> Amount: Medicaid --> Amount: SNAP --> Amount: Military Retirement --> Amount: If no assistance from programs above you must select one of the following hardship's: ForeclosureLow Income StatusSudden Medical ExpensesOther Any other explanation of financial hardship. Approval will be on a case by case basis. Documents might be requested. *PET INFORMATION SECTION* Please Enter ALL Current Pet Information Pet 1 Information Pet Name: Dog Or Cat? DogCatOther (If other - What kind of pet?) --> Male Or Female? MaleFemale Age: Weight: Current On Rabies? YesNo Is This Pet Fixed YesNo You must be willing to neuter! Are you willing to neuter this pet? YesNo Food: (Please list 3 or more acceptable brands - we will do our best) 1: 2: 3: 4: Cat Litter: (Please list 3 acceptable brands - we will do our best) 1: 2: 3: Special Food Needs/Allergies: 1: 2: 3: Other Information We might Need To Know: Pet 2 Information Pet Name: Dog Or Cat? DogCatOther (If other - What kind of pet?) --> Male Or Female? MaleFemale Age: Weight: Current On Rabies? YesNo Is This Pet Fixed YesNo You must be willing to neuter! Are you willing to neuter this pet? YesNo Food: (Please list 3 or more acceptable brands - we will do our best) 1: 2: 3: 4: Cat Litter: (Please list 3 acceptable brands - we will do our best) 1: 2: 3: Special Food Needs/Allergies: 1: 2: 3: Other Information We might Need To Know: Pet 3 Information Pet Name: Dog Or Cat? DogCatOther (If other - What kind of pet?) --> Male Or Female? MaleFemale Age: Weight: Current On Rabies? YesNo Is This Pet Fixed YesNo You must be willing to neuter! Are you willing to neuter this pet? YesNo Food: (Please list 3 or more acceptable brands - we will do our best) 1: 2: 3: 4: Cat Litter: (Please list 3 acceptable brands - we will do our best) 1: 2: 3: Special Food Needs/Allergies: 1: 2: 3: Other Information We might Need To Know: Where did you hear about LAPP? The LAPP board meets on the first Monday of the month (excluding holidays). Applications must be received by the last day of the previous month to be considered. Distribution is once per month. Accepted applicants will be contacted prior. It is the applicant’s responsibility to arrive at the distribution location on time. Failure to do so will mean suspension of distribution for that month. By initializing, I agree to the terms and conditions of the LAPP Program. Type Initials --> By electronically submitting this application you agree to the above items and that all information listed is true to the best of your knowledge.