FY 2022 John R Justice (JRJ) Pre-Application Survey

1.Legal Name(Required.)

2.Home Address

Please include city, state, and zip code(Required.)

3.E-mail(Required.)

4.Phone(Required.)

5.Job Title(Required.)

6.Number of Years Employed?(Required.)

7.Employing County(Required.)

8.Are You a Full Time Employee?(Required.)

9.Has the JRJ program impacted your decision to remain employed with a government entity?(Required.)

10.Have you received JRJ assistance previously?

(Required.)

11.Income Source

Select the source of your 2021 Federal Taxable Income from the appropriate line in your 2021 Federal Tax return, then Enter the Amount below.(Required.)

12.Federal Taxable Income Amount(Required.)

13.County of Residence(Required.)

14.Loan Balance

Enter the Total Principal Balances as of April 1, 2023 for ALL eligible loans.(Required.)