On-Going Assistance Application

Please fill in as many fields as possible and click the SUBMIT button at the bottom of the page. All information is confidential and will be used for Take The Lead purposes only.

(Note that information entered into this form is protected by a secure Internet connection using 128 bit encryption to protect the privacy and security of your information.)

INVOLVEMENT IN THE SPORT OF DOGS

REFERENCES

MEDICAL SITUATION & ASSISTANCE

COVERAGE

HEALTH INSURANCE INFOMEDICAL CARE COVERAGE

SPECIFIC NEEDS

EMPLOYMENT STATUS

ASSETS

Please include a copy of last year's tax return (1040)

Drop a file here or click to upload Choose File
Maximum upload size: 67.11MB

Present Annual Income (documentation may be required)

LIVING ARRANGEMENTS

HOUSEHOLD MEMBERS

Optional alternate contact person (social worker, lawyer, family member, friend) - I authorize Take The Lead, Inc. to speak to the following person about my application if you are unable to contact me.

CERTIFICATION STATEMENT

I certify that the above information is true and correct. I understand the following:

* The information is being given in connection with services provided by Take The Lead, Inc.

* The Take The Lead Assistance Administration Committee may verify the information given on this form.

* If I deliberately misrepresent information on this application, I agree to repay benefits provided by Take The Lead, Inc. and I may be prosecuted under the applicable State and Federal statutes.

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