* 1. What town/city do you live in?

* 2. Household size:

* 3. Please indicate what gender you identify as:

* 4. What is your age group

* 5. Housing (please select one below)

* 6. Please select the option that best describes your race.

* 7. Are you Hispanic

* 8. How much income does your household have in a year?

* 9. In your home, what language is spoken most?

* 10. Are you or a household member currently in the Armed Forces or a Military Veteran?

* 11. Please check all sources of income in your household

* 12. Please select the highest level of education completed in your household

* 13. Has your household needed assistance this past year of any kind?

* 14. If yes, were you able to get access to the assistance you needed?

* 15. From what agency/resource did you receive assistance? List multiple agencies if needed.

* 16. Based on the current needs of your household and your community, please rate each of the issues below.

  A critical concern Somewhat a concern Not at all a concern
Food costs
Access to healthy foods
Housing /rent costs
Homelessness
Home repairs
Reducing utility costs
Increasing income
Help with managing money
Help paying utility bill(s)
Credit card or loan debt
Parenting support and education
Children’s education/tutoring
High school drop-outs
Affordable daycare or before/after school care
Neighborhood Safety and Security
Paying for college/higher education
Health Insurance/ Healthcare Costs
Dental and/or Vision Care
Programs for youth/teens
Juvenile Delinquency/Crime
Drug or Alcohol Abuse
Domestic Violence
Programs and services for Senior Citizens
Services for Disabled people
Veterans’ Services
Mental Health Services
Language Barrier(s)
Immigration/citizenship issues
Incarceration /reintegration issues
Finding a job
Job Training

* 17. Which ONE item of the list above is MOST important need right now?

* 18. Please share any comments about the availability of services or other unmet needs in your community?

* 19. If you would like to participate in the raffle, let us know how to contact you.

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