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Briefly describe the specific need requested: (Please include if this is a one-time need or reoccurring)

Briefly describe the situation of why the need is requested:

Summarize the specific financial need:

How much is needed? What agency will be paid? What is the account information?

Please attach copies of bills, notices, and other documents that validate the cause and extent of your financial need

All documents have to be in the same folder.

Are you eligible for Medicare and/or Medicaid?

Are you receiving other assistance from any other government or private programs? If yes, please describe.

Have you previously applied for assistance from The Pearl Mae Foundation?

Release of photographs, images, and/or storylines:

Acknowledgment: