What town/city do you live in?

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

Household size:

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* 2. Household size:

Please indicate what gender you identify as:

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* 3. Please indicate what gender you identify as:

What is your age group

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* 4. What is your age group

Housing (please select one below)

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* 5. Housing (please select one below)

Please select the option that best describes your race.

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

Are you Hispanic

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* 7. Are you Hispanic

How much income does your household have in a year?

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

In your home, what language is spoken most?

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

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

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

Please check all sources of income in your household

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

Please select the highest level of education completed in your household

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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