The Onyx & Breezy Foundation
P.O. Box 857, Tuxedo Park, NY 10987 (201-782-7400)
www.onyxandbreezy.org
Questionnaire
Applicant:
Name Age:
S
pouse’s Name Age:
C
hildren Ages:
H
ow did you hear about us?
If so, what was the approximate Date? / / How did we assist you? Amount: $
Own Home: Yes No Address: City: State: Zip: Home Phone:
Email address: Market Value: Mortgage Amount: Total monthly payment including taxes:
Applicant Employment:
Address: Telephone: Position: Annual Compensation:
Spouses/Employment:
Address: Telephone: Position: Annual Compensation:
Other sources of Income: Investments (including savings):
Other Debt: College: Credit Cards: Other (List)
Vets name & number: Pets name: Date of birth:
Approximate money spent on animal care (not including Routine Medical cost): Do you have Pet insurance? Yes No
What are you requesting for a donation? Please explain:
The above statements are true & factual.
Sign Name
** Please include copy of Tax Return / Financials Statements & Proof of Non-Profit Status with application.
We are a non-profit 501( c ) (3 ) organization
Have we assisted you before? Yes No
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