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1
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2
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What is your age? Example: 35
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3
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What is your citizenship status in the US?
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4
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What U.S. State or territory do you live in?
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5
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What is your race/ethnicity?
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6
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What is your current employment status?
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7
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Describe your current and past professional experiences.(check all that apply)
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8
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Are you a current or prospective student?
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9
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What is your current marital status?
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10
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Are you a parent or primary caregiver?
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11
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How many people live in your household? Example: 5
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12
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Are any of the following family members deceased (child, parent, spouse)?
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13
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Are you the spouse or surviving dependent of a veteran(alive or deceased)?
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14
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Are you, your spouse, parents or children currently receiving or are you eligible to receive benefits from any of the following programs? (check all that apply)
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15
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Are you or any of your family/household members suffering from an injury or illness?
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16
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Do you need medical advice or guidance for any of the following?(check all that apply)
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17
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Indicate if you or any of your family/household members have a disability.
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18
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What is your household's annual income before taxes? Example: 25000
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19
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How would you characterize your income?
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20
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Do you need Federal income tax information and return preparation assistance?
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21
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Do you have debt in any of the following areas?(check all that apply)
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22
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What describes your current housing / living situation?(check all that apply)
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23
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Are you in need of assistance or guidance regarding any of the following?(check all that apply)
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24
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Do you speak English fluently?
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