Name *

First Name

Last Name

Phone

(###)

###

####

Housing *

Please check the option that best describes your situation.

I have a safe and long-term place to live. I pay my rent or mortgage on time and don’t worry about losing my home.

I can usually afford my home, but sometimes it’s hard to pay rent or I need assistance to cover costs.

I am behind on rent or mortgage, at risk of losing my home, or require housing assistance for most of my rent.

Food Security *

Please check the option that best describes your situation.

I have enough food and don’t need help from food programs.

I can buy food, but sometimes I need help from programs like SNAP or WIC.

I often can’t afford enough food without help and sometimes have to skip meals or go to food pantries.

Healthcare Access *

Please check the option that best describes your situation.

I can pay for medical care, prescriptions, and insurance without any major money problems.

I have some medical costs that are a bit hard to pay, but I can still get the care I need.

I can’t afford the medical care, prescriptions, or insurance I need, and I’m falling behind on medical bills.

Utilities *

Please check the option that best describes your situation.

I always pay for electricity, water, heat, and internet on time without problems.

I can usually pay for utilities, but sometimes I need help covering the costs.

I often have trouble paying for utilities and sometimes lose services because I can’t pay on time.

Transportation *

Please check the option that best describes your situation.

I have reliable transportation to get to work, school, and healthcare appointments without any money problems.

I have transportation, but it’s hard to pay for things like gas, repairs, or fares, and sometimes I need help from others.

I don’t have reliable transportation, which makes it hard to get to work, school, or healthcare appointments.

Childcare (If applicable)

Please check the option that best describes your situation.

I have affordable and reliable childcare that doesn’t cause money problems.

I can find childcare, but it’s expensive and makes it harder to pay for other things.

I can’t afford childcare or don’t have good options, which makes it hard to work or pay my bills.

Medical Debt *

Please check the option that best describes your situation.

I have savings to cover my medical debt. It’s a bit of a strain, but I can still pay for housing, food, transportation, and utilities.

My medical debt is tough, but I can make payments and still afford the basics.

My medical debt is more than 15% of my income (for example, earning $1,000 a month with over $150 in medical payments per month), making it hard to pay for basic needs.

Please check all that apply to you and significantly impact your quality of life: *

I am a single parent with children

I care for a family member with a disability or chronic illness

I have been denied employment due to prior incarceration

I am experiencing homelessness or unstable housing

I have immigration legal expenses

Elderly with limited financial support

None of the above

Date Signed *

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