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* 1. Please identify yourself. I am a: (check all that apply)

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* 2. If you could choose only one service to receive from Community Action, what would it be?

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* 3. Which services would you most like to see continued. Please list your top five services with 1 being the most important and 5 being the least important.

  1 2 3 4 5
Head Start, Early Head Start or GSRP
Senior/Disabled Transportation
Congregate or Home Delivered Meals
Foster Grandparent Program
Emergency Services (utility rent/mortgage assistance)
Commodity Supplemental Food
Home Weatherization
Home Rehab/Repair
Does not apply to me

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* 4. Is there a service that you need that is not on the list above? If so, please tell us what service(s) you may need.

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* 5. What is the zipcode in which you live?

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* 6. In what county do you live?

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* 7. What City or Township do you live in?

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* 8. Your Race: (check all that apply)

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* 9. Are you of Hispanic origin?

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* 10. Is English the primary language spoken in your home?

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* 11. Your age:

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* 12. Your Gender:

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* 13. Your Family Type: (check only one)

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* 14. Highest grade of school completed:

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* 15. What is your annual household income (before taxes)?

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* 16. Your Source of Income (check all that apply)

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* 17. In general, do you feel that you are financially:

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* 18. Does anyone in your household have a disability? (Check all that apply)

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