General Emergency Monetary Support Application

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Through our G.E.M.S. Program, PEARL assists with clients financially with basic needs like: rent/mortgage, utilities, phone, insurance, gas, food, etc.

To qualify for services from PEARL for you or your child(ren), you must:

Be a single parent with at least 50% legal custody to a child/children under 18 years of age
Reside in Boulder County (preference in services are first given to St. Vrain Valley School District Residents)
Be receiving some form of government or public assistance
Be motivated to become self-sufficient

Proof of eligibility and need will be required (i.e. lease, bill, divorce decree, child custody agreement, birth certificate for children, etc.)

Please fill out this form in it's entirety; failure to do so may prevent assistance.

Please use "n/a" only when the question doesn't apply to you.

Email *

Full Name

Today's Date

YYYY

Do you have minor (under 18 years of age) children in your custody at least 50% of the time?

Yes

Clear selection

What are the names and ages of each child in your household?

Contact Phone

Can you receive texts at the above number?

Yes

Clear selection

Current Address (Include City, State, Zip Code)

Why type of assistance are you requesting? Please be as specific as possible and include due dates and exact amounts. *

Are there any other adults in the home? If so, please list their names and relations to you, as well as any way in which they contribute to the household. (An adult is considered 18 years and older.)

Please list the person or agency that you were referred by.

Please provide us with details of what is happening with your current situation (i.e. loss of employment, illness, any current extenuating circumstances).

What is your employment situation? (Title, Employer, length of employment, number of hours per week, etc.)

Are you currently enrolled in school? If so, where and what are you studying?

What public assistance benefits do you receive?

Section 8 Housing Assistance

TANF

SSDI

Food Stamps

Unemployment

Medicaid Card

Other:

Clear selection

What other assistance (non-government) have you received in the last 6 months?

Child Support

OUR Center

A Woman's Work

Food Banks

Other:

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List any education assistance you are receiving. (i.e. student loans, grants, etc.)

List all Monthly Income, including salary/wages, child support, Social Security, disability benefits, etc. Please label and list individually below.

List all Monthly Expenses including rent/mortgage, utilities, phone, car payment, insurance, gas, food, medical expenses, etc. Please label and list individually below.

Are you currently a participant in any of our programs? Please note, participation is NOT required to be a recipient. Check all that apply.

Focus PEARL Program

PEARL Kid's Mentoring

Above All Scholarship Recipient

Attending Wednesday Single Mom's Group at Lifebridge

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Have you received any services or assistance from PEARL in the past year?

Car Care Clinic

Car Repair Assistance

Recipient of Vehicle Donation

Assistance with groceries and/or gas.

Rent/Mortgage Assistance (fill in amount in other)

Utility/Bill Assistance (fill in amount in other)

Other:

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