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* 1. In which county do you live or is your organization located?

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* 2. Please indicate your role in our community?

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* 3. Please rank the following (1-9) in the order in which you feel has a direct impact on poverty in your community. (1 indicates the greatest impact, 9 indicates the least impact)

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* 4. If there is an additional cause of poverty not listed above, please describe below:

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* 5. If applicable, please identify which of the following might prevent you from working as much as you need or want to:

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* 6. Has there been a time in the last year that you or someone in your immediate family (check all that apply):

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