G.E.M.S.

Application for General Emergency Monetary Support

Pearl Promise Programs & Services Qualifications

Incomplete applications will not be considered. Failure to complete the entire application will automatically disqualify you from receiving assistance. *Indicates a required field.

You must be a single parent with at least 50% legal custody of one or more children under 18 years of age
You must reside in Boulder County, preferably within the St. Vrain Valley School District.
You must currently be receiving some form of government or public assistance.
You must be motivated to become self-sufficient.

Before you Begin:

It will take approximately 30 minutes to complete this application.
Please provide as much detail as possible to help us understand your situation. Documentation (such as copies of bills with account information) may be required.
Please note that submitting an application is the first step in the process and does not guarantee approval or fulfillment of the request. All applications are reviewed based on established criteria, availability, and eligibility. We appreciate your understanding and patience as we evaluate each request carefully.

Basic Information

Today's Date

Full Legal Name

Email

Contact Phone

Can you receive texts at the above number?

Yes

No

Eligibility Confirmation

Are you a single parent with at least 50% legal custody of one or more children under the age of 18?

Yes

No

If yes, please list the names and ages of your children. If not, please cancel your submission. Pearl Promise programs are available ONLY to single parents with a child under 18 years of age.

Do you currently reside in Boulder County?

Yes

No

Address (include Street Address, Unit #, City, State, Zip)

Please attach proof of residency in Boulder County (e.g. Drivers License, Utility Bill, Rent document)

Are there any other adults - aged 18 or older - living in the home? If so, please list their names, relationship to you, and their financial contribution.

What type of assistance do you need? Please be as specific as possible. Include exact amounts needed, due dates, and information about HOW to pay and WHO to pay.

Please explain your current situation, why you need help, and/or how you this situation developed.

Are you currently employed?

Yes

No

Name of Company and Your Position/Title (If you are not employed, enter "NA")

If not employed, how long have you been out of work? What was your last job? (If you are employed, enter "NA")

What is your monthly income? Please list each type separately including: Salary, Child Support, Social Security, Disability benefits, etc. For example: Wages - $2000/month; Child Support - $250/month; etc.

What are your monthly expenses including rent/mortgage, utilities, phone, car payment, insurance, gas, food, medical expenses, etc. Please list individually. For example: Rent - $1800/month; phone - $100/month; fuel - $75/month

Do you owe anyone money? What is your amount of debt to any type of creditor? Include past due bills & amounts. Include credit cards, personal loans, family loans, etc.

How did you hear about Pearl? Who referred you to Pearl?

Please indicate any Pearl Programs that you have participated in and/or benefitted from in the past.

Have you ever volunteered with Pearl? If yes, please describe when, where, and with whom.

How do you "give back" to the community? Are you able and willing to help Pearl through volunteer service - occasionally or on a regular basis?

Are you currently attending a weekly spiritual support group and/or meeting?

Yes

No

If yes, where, and how often do you attend?

What is your current plan to reach self-sufficiency? (e.g. attend school, buy a car, start applying for higher paying job, etc.)

If Pearl is not able to help with this request at this time, what will you do?

By entering your full name below, you are electronically signing this form and therefore attesting that all of the information you've provided is accurate and true. Completing this application does not guarantee assistance or admittance to the program.