Help Me Keep My Pet Request

The purpose of the Help Me Keep My Pet program is to help keep pets in Harris, Montgomery and surrounding counties with their families, out of shelters, and off the streets. Please reach out with any pet related problems you and your family are experiencing. While we are unable to assist in all situations, we will definitely do our best to help! Assistance is provided on a first come, first served basis, dependent upon the need as well as availability of supplies and funding. This is a short-term stopgap program for emergencies only. It is not intended for permanent ongoing assistance. Data is collected for grant/fundraising purposes only. Decisions are not based upon personal data.
Your First Name *
Your Last Name *
Your Age *
What is your ethnicity? (Please share to help us receive funding for our program.) *	White Non-Hispanic Hispanic Africian American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander
Your Email Address *
Your Address *
City *
State *
Zip Code *
County *
Cell Phone Number *
Home Phone Number
Work Phone Number
How many people reside in your home? Please list the number of adults and children ages 17 and under. *
What is your approximate annual household income? * For all requests aside from pet pantry, please email a current form of income or benefit verification to help@helpmekeepmypet.com.
What benefits are you receiving? (Select all that apply.) * For all requests aside from pet pantry, please email a current form of income or benefit verification to help@helpmekeepmypet.com.	Social Security Unemployment Food Stamps/SNAP TANF Medicaid CHIP SSI WID AABD Public Housing or Section 8 Housing Low Income Energy Assistance Telephone Lifeline Comunity Care via DADS LIS in Medicare ("Extra Help") Needs-based VA Pension Child Care Assistance under Child Care and Development Block Grant County Assistance, County Health Care or General Assistance None of the Above
If you are not low income and not receiving pubic assistance, please explain your situation and long-term plan.
If we cannot help you, what is your alternative plan? *
Please list all pets in your household. Include name, species, sex, breed, color, weight, age and whether the pet is spayed/neutered. *
Please tell us how we can help. *
Explain any special dietary needs.
How did you hear about our program? *
By accepting help through this program, you agree you will not sell any items given to you. You also agree we may use your story, including photos, for grant writing and fundraising purposes. Filling out this form does not guarantee assistance.
Signature *	Clear

Pet Food Pantry Request 080624