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Financial Capabilities - Online Homebuyer Education
Copyright ©2013 Neighborhood Reinvestment Corporation. All rights reserved.
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1.
Customer Information
(Required.)
Name
Address
Phone Number
Email
Today's Date
Please tell us why you are here today
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2.
Over the past 3 months, have you followed a personal budget, spending plan or financial plan?
(Required.)
Yes
No
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3.
Do you currently have any of the following types of accounts at a bank or credit union? Check all that apply.
(Required.)
Checking
Savings
Prepaid Debit Card
None of the above
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4.
Are you saving for a specific financial goal?
(Required.)
Yes
No
5.
If yes, what is that financial goal?
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6.
Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use such as saving for retirement or education?
(Required.)
Yes
No
7.
OPTIONAL: Below is a list of places where people sometimes put money that they set aside as savings. Please indicate whether or not you have set aside money for savings in these places during the past 6 months by answering “yes” or “no” for each one.
Yes
No
Someplace at home
Yes
No
Savings account
Yes
No
Checking
Yes
No
A Certificate of Deposit, sometimes called a CD, for a set period of time at a bank or credit union
Yes
No
United States savings bond
Yes
No
Individual Development Account, sometimes called an IDA, where the money deposited for homeownership or education is matched with additional funds
Yes
No
Retirement Account [IRA, 401(k), or403(b)]
Yes
No
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8.
Have you set aside funds that would cover your expenses for 3 months if you or someone in your family lost a job, got sick, or had another emergency?
(Required.)
Yes
No
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9.
Below is a list of ways in which people sometimes pay for their expenses. Please indicate whether or not you regularly use these methods to pay for your expenses by answering “yes” or “no” for each one.
(Required.)
Yes
No
Cash
Yes
No
Prepaid debit card (not to obtain cash)
Yes
No
Credit card
Yes
No
Personal check
Yes
No
Money order
Yes
No
Electronic, online, or automatic transfer of funds
Yes
No
10.
OPTIONAL: If you rent your home, which payment method do you use most often to pay your rent?
11.
OPTIONAL: If you own your home, which payment method do you use most often to pay your mortgage?
12.
Below is a list of ways in which people sometimes obtain cash that they want or need. Please indicate whether or not you have used the following activities during the past 6 months by putting a check next to the way you obtained cash. Check all that apply.
I obtained cash using a debit card
I obtained cash from a payday loan in anticipation of an upcoming pay check
I used a check cashing store where I paid a fee to get cash in exchange for a check
I sold something to a pawn shop
I obtained a loan that required me to transfer the title of my automobile
I obtained a tax refund on the same day I filed my income tax return
I over-withheld income taxes throughout the year so that I would get a big refund when I filed my tax return
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13.
Below is a list of ways in which people sometimes pay for things they purchase. Please indicate whether or not you have used each of the following methods during the past 6 months by answering “yes” or “no” for each one.
(Required.)
Yes
No
Rented something from a rent-to-own store
Yes
No
Purchased a money order
Yes
No
Used a layaway plan at a retail store
Yes
No
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14.
What does the term “financial security” mean to you?
(Required.)
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15.
Using this definition (to the previous question), how secure do you feel your financial situation is right now?
(Required.)
Very secure
Secure
Somewhat secure
Not very secure
Not at all secure
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16.
Age
(Required.)
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17.
Gender
(Required.)
Male
Female
18.
Race
Black/African American
Caucasian/White
American Indian/Aleut/Eskimo/Alaska Native
Asian
Native Hawaiian/Pacific Islander
Mixed Race
19.
Ethnicity
Yes, Hispanic/Latino/Latina
No, not Hispanic/Latino/Latina
20.
Credit Score
Current Credit Score
Date Credit Score was pulled
21.
Types of Debt
Store and credit card debts
Student/Educational loans
Unpaid medical bills not covered by insurance
Unpaid medical bills not covered by insurance
Unpaid legal bills
Unpaid taxes
Money owed to private individuals
Home improvement loans
Money owed on credit lines
22.
Other types of debt: please indicate source and amount
Other
Other
Other
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23.
Total Debt: sum "types of debt" and all "other debt"
(Required.)
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24.
Total Savings
(Required.)
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25.
Are you participating as part of an eviction prevention program?
(Required.)
Yes
No
26.
Notes:
27.
Which financial capability services have you participated in? Check all that apply
Workshops
Coaching or counseling
Other
