SELF Pre-Finance Questionnaire Question Title * 1. Please provide your contact Information in order to link to your application. First and Last Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address Phone Number * Question Title * 2. What prompted you to seek our services? [Choose at least one] High utility bill Leaking/ Damaged roof Damaged or inoperable A/C Need for home improvements such as windows, doors, insulation, weatherization, etc. Interested in “Green” technologies (renewable energy and environmental awareness) Opportunity to access affordable financing through SELF Credit rebuilding opportunity Reduce home insurance cost Question Title * 3. Which Aspects of your life do you feel would improve if given access to SELF financing? [Directions: Each given aspect must contain a different level of importance rating, no duplicate ratings. Choose in order of importance, 1 (most important) to 7 (least important).] *If Other is not an option, enter '7' for that answer. (All 7 answers require a different number for each one.) 1 2 3 4 5 6 7 Safety (Home structure safety such as roof was caving in or leaking) 1 2 3 4 5 6 7 Security (Impact windows, doors) 1 2 3 4 5 6 7 Health (cleaner, cooler air - no mold or mildew) 1 2 3 4 5 6 7 Cost of Home Insurance 1 2 3 4 5 6 7 Cost of energy and/or water bills 1 2 3 4 5 6 7 Quality of life in home 1 2 3 4 5 6 7 Other Question Title * 4. Why did you select SELF for your home improvement project? [Directions: Choose at lease one.] Unable to obtain other sources of financing Lower interest rates than other available offers I trust SELF as a Community Development Financial Institution (CDFI) SELF is a non-profit Project Management It was highly recommended to me Other Other (please specify) Question Title * 5. Do you have any suggestions to help us improve our program? (please only use the space provided) Done