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* 1. How can we contact you?

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* 2. Primary reason for your need (check all that apply)

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* 3. Determine debt to income ratio

(Expenses are but not limited to

Mortgage, rent
Property taxes
Strata fee / condo fee
House / tenant insurance
Utility bills (cable, cell, electricity, water, etc.)
Lease / car loan payment
Vehicle insurance
Life / Disability / Extended health (or other) insurance
Bank fees
Debt payments/debt repayment plan/student loans
House insurance
Vehicle insurance
Clothing & shoes
Health expenses
Vehicle maintenance
Groceries
Personal care items (drugstore)
Fuel / public transportation costs
Parking
Clothing & shoes
Daycare
Work lunches & snacks
Babysitting
Hair care)

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* 4. Can you supply copies of your income & expenses

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* 5. Has this experience impacted your household budget in any of the following (check all that apply)

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* 6. How many people are in your household

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* 7. Has anyone in your household ever been charged, or convicted of a crime

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* 8. Gender

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* 9. Race

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* 10. Highest level of education

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