1. County of Residence
Mercer Summers Monroe

2. City of Residence
 

3. Gender
Male Female

4. Age
18 - 23 24 - 44 45 - 54 55 - 69 70+

5. Ethnicity / Race
White African American Hispanic Other Multi-Race (Any 2 or more of above)

6. Family Size
1 2 3 4 5 6 7 8 More than 8

7. Family Type
  Single Parent Female Single Parent Male 2 Parent Household Single Person Two Adults / No Children Grandparents with Grandchildren Other

8. Housing
Own Rent Homeless Other

9. Health Insurance
Yes No

10. Source of Family Income
Employment Only Employment + Other Unemployment Insurance Pension Social Security SSI TANF Other

11. Income Level
Less Than $10,000 $10,000 to $20,000 $20,000 to $30,000 $30,000 to $40,000 $40,000 +

12. Education Level (for adults 24 and older)
I am under 24 years old 0 - 8th grade 9th - 12th grade / Non-Graduates High School Graduate / GED 12+ Some Secondary 2 - 4 Year College Graduates

Are you receiving assistance with or need assistance with any of these issues?

Employment

Have        Need            Does not apply

Food

Have        Need            Does not apply

Child Day Care Food Assistance

Have        Need            Does not apply

Child Care Age 0 - 3

Have        Need            Does not apply

Child Care Age 3 - 5

Have        Need            Does not apply

Child Care Age 5 - 12

Have        Need            Does not apply

In Home Child Care

Have        Need            Does not apply

In Home Adult Care

Have        Need            Does not apply

In Home Senior Care

Have        Need            Does not apply

Senior Meals / Services

Have        Need            Does not apply

Clothing

Have        Need            Does not apply

House Payments

Have        Need            Does not apply

Rental Accommodations

Have        Need            Does not apply

Utility Bill Assistance

Have        Need            Does not apply

Weatherization / Home Improvements

Have        Need            Does not apply

Transportation

Have        Need            Does not apply

Job Training / Education

Have        Need            Does not apply

Computer Access

Have        Need            Does not apply

Mental Health Counseling

Have        Need            Does not apply

Drug / Alcohol Abuse Counseling

Have        Need            Does not apply

Domestic Violence Counseling

Have        Need            Does not apply

Dental Care

Have        Need            Does not apply

Legal Aid

Have        Need            Does not apply

Comments or Suggestions?