Pearl Mae Foundation

First Name *

Last Name *

Date of Birth *//

Home Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

Reason for Need *

Situation *

Summary *

Amount Needed *

What is your annual income? *

What is your net monthly income after taxes? *

Medicaid/Medicare Eligibility *

Amount Needed (copy) *

Previous Application *

Previous Application Date//

If yes, when?

File Upload (copy)

All documents have to be in the same folder.

File Upload

All documents have to be in the same folder.

File Upload (copy) (copy)

All documents have to be in the same folder.

Release of photographs, images, and/or storylines *

For good and valuable consideration, the receipt of which is hereby grant PEARL MAE FOUNDATION, INC. (“PMF Corp”) permission to use my likeness, image, photograph, and/or storyline in any and all of its publications, including but not limited to all of PMF Corp’s printed and digital publications. I understand and agree that any photograph or image or story using my likeness will become property of PMF Corp and will not be returned. I hereby hold harmless and release and forever discharge PMF Corp from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other person(s) acting on my behalf or on behalf of estate have or may have by reason of this authorization

Acknowledgement *

I acknowledge that all the information I have provided both- verbally and in writing related to this request for assistance is true. I understand that the Pearl Mae Foundation Board of Directors will review my request for assistance and make a final decision to approve or reject my request.