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GovBenefits.gov - Your Benefits Connection
GovBenefits.gov - Your Benefits Connection Group of potential benefit recipients - Digital Imagery© copyright 2001 PhotoDisc Inc.
 
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Questionnaire

A maximum number of 137 question(s) remaining.
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Answer questions and review all benefits you may be eligible to receive.

Depending on your answers, you may be presented with additional questions. To ensure the most accurate results, you should answer all the questions listed. You may click the 'Stop and View Results' button at any time to review results based on the answers you already submitted. Your answers are used only to determine potential eligibility. GovBenefits.gov does not keep any data you enter.
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1
What is your gender?
Female
Male
No Answer
2
What is your age? Example: 35
3
What is your citizenship status in the US?
US Citizen
US National
Permanent Resident
Legal alien
Other
No Answer
4
What U.S. State or territory do you live in?
5
What is your race/ethnicity?
African American
Alaskan Native
Amerasian
Caucasian
Asian
Cuban
Haitian
Hispanic
Native American /American Indian
Native Hawaiian/Pacific Islander
6
What is your current employment status?
Employed (full-time)
Employed (part-time or seasonal)
Under-employed (working for very low wages)
Unemployed or about to become unemployed
No Answer
7
Describe your current and past professional experiences.(check all that apply)
Agricultural producer / Farmer
Aquaculture operator
Clinical research
Coal miner
Dairy farmer
Educator (teaching, training)
Elected official
Emergency response worker
Federal employee
Firefighter
Fisherman
Health care professional
Law enforcement officer
Long shore or harbor worker
Migrant or seasonal farm worker
Military
Musician
Post-doctoral research
Practicing artist
Published writer / Poet
Railroad worker
Rancher
Translator
8
Are you a current or prospective student?
Yes
No
No Answer
9
What is your current marital status?
Divorced
Married
Remarried
Single
Widow(er)
10
Are you a parent or primary caregiver?
Yes
No
No Answer
11
How many people live in your household? Example: 5
12
Are any of the following family members deceased (child, parent, spouse)?
Spouse
Parent(s)
None of the above
13
Are you the spouse or surviving dependent of a veteran(alive or deceased)?
Yes
No
No Answer
14
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)
Specially adapted housing grant
DOD tricare(formerly CHAMPUS)
Food Stamps
United States government life insurance
Servicemembers' Group Life Insurance
Government Service Life Insurance
Medicaid
Medicare
National Service Life Insurance
A private traditional pension plan that has ended
Social Security
Temporary Assistance for Needy Families
Unemployment Benefits
Veterans' disability compensation
Veterans' Group Life Insurance
Vocational Rehab Training
15
Are you or any of your family/household members suffering from an injury or illness?
Family/household member
Self
None of the above
16
Do you need medical advice or guidance for any of the following?(check all that apply)
Treatment of drug or alcohol dependency
Hepatitis A, B, or C
Lead paint exposure
Poisons
Prevention of substance abuse
17
Indicate if you or any of your family/household members have a disability.
Child(ren)
Spouse
Parent
Self
None of the above
18
What is your household's annual income before taxes? Example: 25000
19
How would you characterize your income?
Above average income
Moderate income
Low income
Very low income
No Answer
20
Do you need Federal income tax information and return preparation assistance?
Yes
No
No Answer
21
Do you have debt in any of the following areas?(check all that apply)
Delinquent federal debt
Housing debt/mortgage
Education Loans
22
What describes your current housing / living situation?(check all that apply)
Live in or own a condominium
Member of a housing cooperative
Live in a high-poverty community
Homeless / Live in a Shelter
Current or prospective homeowner
Live on or near an Indian reservation
In need of aid to obtain decent, safe, and/or sanitary housing
At risk for exposure to lead poisoning
Damaged by a Presidentially declared disaster
Live in public housing
Renting
Live in a rural area
Lost the majority of income because an employer or business was harmed by either a Presidentially declared disaster or closures mandated by a government agency
23
Are you in need of assistance or guidance regarding any of the following?(check all that apply)
Disaster relief
Addressing the problems of drug-related crime in your neighborhood
Land or property ownership
Literacy program for incarcerated adults
Training or retraining to develop new job skills
Veteran burial issues
24
Do you speak English fluently?
Yes
No
No Answer
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