Computers with Cause application Survey

1.How can we contact you?(Required.)

Full name

Street address

Zip code

Phone number

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

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)

(Required.)

What is your total expenses per month

What is your total income after taxes per month

4.Can you supply copies of your income & expenses(Required.)

Yes

No

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

Reduced earning potential

Residual debt

Difficulty obtaining credit

Degree in a field where employment cannot be acquired

6.How many people are in your household

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

Yes

No

8.Gender(Required.)

Female

Male

Trans (He, Him, his)

Trans (She, her, hers)