Community Financial Assessment

Community Financial Assessment
Help us understand the financial realities and needs within your community. Please answer all questions honestly and to the best of your ability.
Full Name
First NameLast Name
Age
City or Community Name
How many people live in your household (including yourself)?
What is your primary source of income?
Other
Please indicate your approximate monthly household income (before taxes):
Monthly Household Expenses
Rows Estimated Amount ($)
Rent or Mortgage
Utilities
Food/Groceries
Transportation
Healthcare
Education/Childcare
Other
Which of the following assets do you or your household own? (Select all that apply)
Other
Do you or your household have any of the following liabilities? (Select all that apply)
Other
How would you rate your household's current financial well-being?

1
2
3
4
5
6
7
8
9
10
1 is Very poor, 10 is Excellent

Please indicate your level of agreement with the following statements:

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I feel confident managing my finances.
I have access to affordable financial services.
I can cover an unexpected $500 expense.
I regularly save a portion of my income.
I worry about my financial future.

What are your household's biggest financial challenges? (Select up to three)
Other
How would you prefer to receive financial education or support? (Select all that apply)
Other
Please share any additional comments or suggestions about financial needs in your community.
Should be Empty:

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