Baseline Financial Profile
Have you been to the John Boner Neighborhood Centers before?
Yes
No
I'm not sure
Name*
First Name
Initial
Last Name
Suffix
Sr.
Jr.
III
IV
Number of household members 18 years or older. (Please INCLUDE YOUR SELF in count.)*
Just myself
Two adults
Three adults
Four adults
More than four adults
Number of minors (children under 18) in the household*
Your Living Arrangement*
House/apartment is owned by household member
Household member pays full rent for house/ apt.
Household member pays subsidized rent for house/ apt.
Household stays in the house/apt. for free
Household is homeless (without a roof) or in a shelter
Date/Time
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