Financial Capabilities - Online Homebuyer Education

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* 1. Customer Information

Name

Address

Phone Number

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?

Yes

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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.

Checking

Savings

Prepaid Debit Card

None of the above

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* 4. Are you saving for a specific financial goal?

Yes

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* 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?

Yes

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* 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	Someplace at home Yes	Someplace at home No
Savings account	Savings account Yes	Savings account No
Checking	Checking Yes	Checking No
A Certificate of Deposit, sometimes called a CD, for a set period of time at a bank or credit union	A Certificate of Deposit, sometimes called a CD, for a set period of time at a bank or credit union Yes	A Certificate of Deposit, sometimes called a CD, for a set period of time at a bank or credit union No
United States savings bond	United States savings bond Yes	United States savings bond No
Individual Development Account, sometimes called an IDA, where the money deposited for homeownership or education is matched with additional funds	Individual Development Account, sometimes called an IDA, where the money deposited for homeownership or education is matched with additional funds Yes	Individual Development Account, sometimes called an IDA, where the money deposited for homeownership or education is matched with additional funds No
Retirement Account [IRA, 401(k), or403(b)]	Retirement Account [IRA, 401(k), or403(b)] Yes	Retirement Account [IRA, 401(k), or403(b)] 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?

Yes

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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.

	Yes	No
Cash	Cash Yes	Cash No
Prepaid debit card (not to obtain cash)	Prepaid debit card (not to obtain cash) Yes	Prepaid debit card (not to obtain cash) No
Credit card	Credit card Yes	Credit card No
Personal check	Personal check Yes	Personal check No
Money order	Money order Yes	Money order No
Electronic, online, or automatic transfer of funds	Electronic, online, or automatic transfer of funds Yes	Electronic, online, or automatic transfer of funds No

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* 10. OPTIONAL: If you rent your home, which payment method do you use most often to pay your rent?

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* 11. OPTIONAL: If you own your home, which payment method do you use most often to pay your mortgage?

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* 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.

	Yes	No
Rented something from a rent-to-own store	Rented something from a rent-to-own store Yes	Rented something from a rent-to-own store No
Purchased a money order	Purchased a money order Yes	Purchased a money order No
Used a layaway plan at a retail store	Used a layaway plan at a retail store Yes	Used a layaway plan at a retail store No

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* 14. What does the term “financial security” mean to you?

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* 15. Using this definition (to the previous question), how secure do you feel your financial situation is right now?

Very secure

Secure

Somewhat secure

Not very secure

Not at all secure

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* 16. Age

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* 17. Gender

Male

Female

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* 18. Race

Black/African American

Caucasian/White

American Indian/Aleut/Eskimo/Alaska Native

Asian

Native Hawaiian/Pacific Islander

Mixed Race

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* 19. Ethnicity

Yes, Hispanic/Latino/Latina

No, not Hispanic/Latino/Latina

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* 20. Credit Score

Current Credit Score

Date Credit Score was pulled

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* 21. Types of Debt

Store and credit card debts

Student/Educational loans

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

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* 22. Other types of debt: please indicate source and amount

Other

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* 23. Total Debt: sum "types of debt" and all "other debt"

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* 24. Total Savings

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* 25. Are you participating as part of an eviction prevention program?

Yes

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* 26. Notes:

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* 27. Which financial capability services have you participated in? Check all that apply

Workshops

Coaching or counseling

Other