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Rags to Riches
Pet Food Assistance Application (Short –Term assistance)
Thank you for contacting the Rags to Riches Cat Rescue
Please fill out this application. Only one member per household may apply.
In order to be considered for assistance, you must:
1. Be 18 years and older.
2. Have picture ID with your current address and one of the following:
a. Medicaid card for adult not a child.
b. EBT card with photo ID & Food Store receipt dated within the previous 3 weeks
c. IRS 1040 Please call for income levels.
d. Social Security Income for adult, if this is your only income.
e. Letter explaining special circumstances and needs for assistance.
3. Understand the food provided is donated and that it may not be your current
brand, therefore your pet(s) could get an upset stomach due to the introduction
of a new food to their diet.
4. Agree to hold the rescue, and its volunteers free from all legal action and
are aware of the risks involved with feeding your pet a new food.
5. Understand the rescue has the right to deny your application.
By signing your name below, you understand and agree to all of the provisions above.
SIGNATURE OF APPLICANT: __________________ DATE: _____
FOR THE RESCUES USE ONLY
Application Processor: ___________________________Date: _____________________
Approved: ______________ Disapproved: ______________ Pending: ______________
Reason for disapproval or pending status: _____________________________________
Amount of food given (in pounds): ___________________________________________
Comments: ______________________________________________________________
1. NAME: _______________________________________DATE: _________________
ADDRESS: _______________________________________ CITY: ______________
___________________ ZIP:___________ PHONE NUMBER: __________________
NUMBER OF HOUSEHOLD MEMBERS:_____ NAMES OF MEMBERS OVER 18
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. How many pets are in your household? ____
3. PLEASE LIST ALL PETS INCLUDING THEIR NAMES, TYPE, BREED, AGE, AND SIZE
PET1’S NAME:______________________________TYPE (cat/dog)____________________
BREED: ________________________________ AGE: ____________ SZ: S M L XL
PET2’S NAME:______________________________TYPE (cat/dog)____________________
BREED: ________________________________ AGE: ____________ SZ: S M L XL
PET3’S NAME:______________________________TYPE (cat/dog)____________________
BREED: ________________________________ AGE: ____________ SZ: S M L XL
PET4’S NAME:______________________________TYPE (cat/dog)____________________
BREED: ________________________________ AGE: ____________ SZ: S M L XL
PET5’S NAME:______________________________TYPE (cat/dog)____________________
BREED: ________________________________ AGE: ____________ SZ: S M L XL
PET6’S NAME:______________________________TYPE (cat/dog)____________________
BREED: ________________________________ AGE: ____________ SZ: S M L XL
(If you need more space please list the pets on the back of this page)
5. How did you hear about the rescue? (optional) _______________________________
6. Have you received assistance from this rescue before? YES___ NO___ When? ____________
7. If you brought your pet(s) with you, would you allow us to take a photo of your pet(s) or you
and your pet(s), to be used for advertising purposes? YES___ NO___ If yes, by signing below
one agrees to relinquish all rights for monetary gain and compensation.
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS
TRUE AND THAT GIVING ANY FALSE INFORMATION WILL RESULT IN THE
DISAPPROVAL OF THIS APPLICATION AND DISQUALIFICATION OF FUTURE
APPLICATIONS.
SIGNATURE: ________________________________________DATE: ___________________
No one in the household is to resell food or items provided by the rescue. If we find out the food was
resold, the household and all members involved will be banned from assistance indefinitely.
Please print this form, complete, and bring with you or mail to:
Rags to Riches Cat Rescue
432 Eaton Ave
Warrenton, NC 27589
