THE INTERNATIONAL BENGAL BREEDERS' ASSOCIATION, INC. Application for TIBBA Bengal Rescue Funds

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*Name  ___________________________________________________________________

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*Address __________________________________________________________________

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*Country, City, State, Zip ____________________________________________________

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*Phone  ______________________  e-mail   _____________________________________

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Explanation of need: ________________________________________________________

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__________________________________________________________________________

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__________________________________________________________________________

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Animal Shelter (if applicable)           Veterinary Clinic/Hospital                             (if applicable) . . Name:____________________________ Name:____________________________ . . Address: __________________________ Address: __________________________ . . Telephone #: ______________________ Telephone #:  ______________________ .

Supporting receipts and or documentation:

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1._________________________________________________________________________

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2._________________________________________________________________________

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3._________________________________________________________________________

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Amount of  funds requested:___________________________________________________

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I declare the following under the penalty of perjury under the laws of the United States of America that all statements are true and accurate, and all accompanied receipts and or documentation are true and accurate copies of such documents.  I also declare that I have not received financial aid for the above mentioned rescue related expenses and I have not previously submitted a request for financial assistance to TIBBA Inc. for these specific expenses.  I also declare that if I receive reimbursement of these rescue related expenses from anyone, including the adopter, I must, within 30 days of receipt of the funds, make restitution to TIBBA.  I declare that any legal fees TIBBA Inc. incurs in upholding this document are my responsibility.

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TIBBA's Officers, Directors, or Bengal Rescue Committee Chairperson has authorization to request and receive information as needed from the Animal Shelter or Veterinary Clinic/Hospital named above to verify the authenticity of the documents and the need in order to determine if funds from TIBBA's Bengal Rescue Fund will be dispersed.

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* Signature ______________________________________ *Date: ____________________

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Send completed form, receipts and/or additional documentation to:

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TIBBA Bengal Rescue 11290 N. Dixie Highway Bonnieville, KY  42713