Newcap, Inc.
1201 Main Street
Oconto, WI 54153
Telephone
(920) 834-4621

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* 1. As the person filling out this form, are you:

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* 2. What County do you live in?

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* 3. What is your Community/Town/City?

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* 4. What is your ZIP Code?

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* 5. Are you:

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* 6. How many live in your household?

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* 7. Please list the number of Male/Female members in your household, including yourself, for each of the following age groups.

  Male Female
Age 0-5
Age 12-18
Age 19-29
Age 30-50
Age 51-65
Age 6-11
Age 66+

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* 8. Regarding race, how many in the household are:

 
White
Hispanic
Black
Hmong
Native American
Other

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* 9. What is the highest grade you completed in school?

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* 10. If you have a spouse or partner living in your household, what is the highest grade they completed in school?

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* 11. What best describes your work situation? Are you employed?

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* 12. If you are employed, is it full-time or part-time?

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* 13. If you have a spouse or partner, what is their work situation? Are they employed?

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* 14. If they are employed, is it full-time or part-time?

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* 15. If you are NOT currently working, is it because of one of the following?

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* 16. If your spouse or partner is not working, is it because of one of the following?

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* 17. What are the sources of your household's income:  (Check as many as apply)

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