FFT Required Demographics for EC, FC, IC (and Intake, if applicable)

Transcription

1 FFT Required Demographics for EC, FC, IC (and Intake, if applicable) Name (last, first, middle initial) Date of Birth (month/day/year) Street Address City, State, Zip Home Phone Cell Work FFT - Gender: Female Male Transgender Social Security # FFT - Marital Status: Common Law Domestic Partner Separated Divorced FFT - Primary Interest at Program Entry (select one): Education/Training Financial Education/Counseling : Married Widowed Single (never married) Income Supports/Public Benefits Job Placement/Career Development FFT - Race: African American/Black American Indian/Alaskan Native Asian Bi-racial Multi-racial Caucasian/White FFT - Ethnicity: Hispanic Non-Hispanic Hawaiian/Pacific Islander FFT - How many in your household (include yourself)? How many children under 18 in household? A household includes,1) one or more heads of household, and 2) their dependents (people for whom they are financially responsible). FFT - Primary Language (the language most often spoken at home): Arabic English Polish Chinese Spanish FFT - Criminal Convictions: Convicted of Felony(ies) Convicted of Misdemeanor(s) only No Convictions FFT - Living Arrangement: House/apartment is owned by household member House/apartment is rented by household member subsidized House/apartment is rented by household member unsubsidized Household stays in house/apartment for free Household is homeless (without a roof) or in a shelter FFT - Highest Grade Completed: High School Diploma GED No High School Diploma Some College Masters Degree FFT - Vocational Training/Bridge Program History: AA Degree Doctoral Degree FFT In school/training at program entry? No Yes (please complete ETO Education Record for current school/training) FFT - In the past 12 months, what is the number of full months worked? A full month refers to either 1) the calendar month, or 2) any 4 continuous weeks. Bachelors Degree Completed Vocational Training/Bridge Program(s) Some vocational Training/Bridge Program(s) No vocational Training/Bridge Program History Veteran of U.S. Military? Yes or No (please circle one) Referred by (name of person / agency): 1

2 FFT - Gross Annual Household Income: Ask participant to estimate household income for the past six months and then multiply by 2. Please include only the following types of income: Income from wages, salaries, tips, etc., Business Income, Interest & Dividend Income, Unemployment & Disability Income, Welfare Assistance (TANF), Alimony, Child Support, Gift Income (regular gifts from non-household members) and Armed Forces Income. FFT - Working at program entry? FFT - If working, is current job also longest job? FFT - If not working, is last job also longest job? N/A participant is not working No (complete ETO Employment Record for last job held) Yes (complete ETO Employment Record for current job) Yes (no need to create separate ETO Employment Record for longest job held) No (please complete a separate ETO Employment Record for longest job held) N/A participant is working at program entry FFT - Consented to participate in research? Yes* No Yes (no need to create a separate ETO Employment Record for longest job held) No (please complete a separate ETO Employment Record for longest job held) *If yes, date consent signed: EMPLOYMENT RECORD (current job or, if not currently working, last job held): Job Title: Hourly Wage: Employer Name: Hours Per Week: Wage Type: Subsidized Job Unsubsidized Job Unpaid/Volunteer Job Benefit Type: Start Employment Date: Job offers Health Insurance and/or Retirement Job DOES NOT offer Health Insurance or Retirement EMPLOYMENT RECORD (longest job held): Job Title: Hourly Wage: If last job held, termination date: Employer Name: Hours Per Week: Wage Type: Subsidized Job Unsubsidized Job Unpaid/Volunteer Job Benefit Type: Start Employment Date: Job offers Health Insurance and/or Retirement Job DOES NOT offer Health Insurance or Retirement If terminated, termination date: EDUCATION RECORD (current school/training program) Institution: Start Education Date: Education Level: High School GED Associates Bachelors Masters Basic Skills, i.e. ABE, ESL Vocational Training (name of program): End Date: Completed Program? Yes No (provide reason for dismissal): Doctoral Degree 2

3 Emergency Contact information Please provide 3 emergency contacts in the event that we are unable to reach you 1. Contact name (first/last name): Best contact phone #: ) - 2. Contact name (first/last name): Best contact phone #: ) - 3. Contact name (first/last name): Best contact phone #: ) -

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5 FFT COMBINED FINANCIAL ASSESSMENT (CFA) BUDGET Participant Name: Date completed/updated: We are about to create a budget. Do you want it to reflect just your own finances, or the finances of your whole household? (Note to participants: please make sure all of your answers stay consistent with your response to this question.) MONTHLY INCOME _Budget reflects participant only Wages (after tax) Worker's Compensation Income from self-employment or business ownership SSI/SSDI Food Stamps/WIC Public Benefits Alimony/Child Support Veteran's Compensation Rental income Budget reflects whole household Income from other household members Interest/Investment Income Income Unemployment Total Monthly Income MONTHLY EXPENSES Rent, Taxes & Home Maintenance Rent Renter's Insurance Mortgage 1 - Primary Residence Mortgage 2, 3, etc. - Primary Residence (combined) HELOC(s) - Primary Residence Real Estate - other than Primary Residence Property tax Homeowner's Insurance Home Maintencance Utilities Gas/Heating Electric Water Trash Sewer Phone (landline) Cell phone (note: cable and internet go in Personal Expense) Transportation Vehicle 1 Payment Vehicle 2 Payment Vehicle 3 Payment Gas Car Insurance Car Maintenance Public Transportation Child/Dependent Related Childcare/Daycare Child Support (paid) Education (for children/dependents) - tuition, books, etc. Health-Related If not deducted from paycheck, Health Insurance If not deducted from paycheck, Dental Insurance Life Insurance (pro-rate if not paid monthly) Monthly Medical & Prescription Bills Credit Card/Loan Payments Revolving Credit Cards Student Loans Consumer Loans - Active Informal Loans - family, friends, etc. Business Loans Food Groceries Food (dining out, school lunch, etc.) Personal Expenses Cable/Internet Laundry/Dry Cleaning Tobacco & Alcohol Clothing &Accessories Hair Products/Toiletries Beauty Salon/Barber Shop Recreation (movies, CD's, vacation, etc.) Miscellaneous Expenses Charitable Giving Gifts to s Newspapers/Magazines Pet Care Allowances for Children/Dependents Membership Dues ( health club, licenses, etc.) Education (not student loan repayment) Financial Fees Total Monthly Expenses MONTHLY NET INCOME Total Monthly Net Income Monthly Savings Target

6 FFT COMBINED FINANCIAL ASSESSMENT (CFA) BALANCE SHEET Participant Name: Date completed/updated: We are about to create a balance sheet. Do you want it to reflect just your own finances, or the finances of your whole household? (Note to participants: please make sure all of your answers stay consistent with your response to this question.) Balance Sheet reflects participant only Balance Sheet reflects whole household ASSETS Checking Account(s) (total balance) Savings Account(s) (total balance) Cash - not in any type of account (total balance) Vehicle 1 (market value) Vehicle 2 (market value) Vehicle 3, 4, 5 etc. (combined market value) Primary Residence (market value) Real Estate - other than Primary Residence (market value) Investments/Assets - Stocks/Bonds/Mutual Funds/IRA/Retirement Accounts, etc. (total value) College Savings Account (529 or other) (total value) Business (estimated market value) LIABILITIES TOTAL ASSETS Housing Mortgage(s) - Primary Residence (combined loan balance) Home Equity Lines of Credit - Primary Residence (portion used) Real Estate - other than Primary Residence (combined loan balance) Transportation Vehicle 1 (loan balance) Vehicle 2 (loan balance) Vehicle 3, Vehicle 4, etc.(combined loan balance) Credit Cards / Loan Balances Credit Card(s) (combined account balances) Student Loans(s) (total balance) Consumer Loans(s) (total balance) Business Loan(s) (total balance) Informal Loan(s) - money owed to family, friends, etc. (total balance) Unpaid Bills (not in collections) Unpaid Utilities (total balance) Total Housing Total Transportation Total Credit Cards/ Loan Balances Unpaid Rent (total balance) Unpaid Medical Bills (total balance) Money owed to banks and/or credit unions, i.e. bank overdrafts, bounced checks (total balance) (total balance) Collections/Judgments Medical Collections only (total balance) All Collections (total balance) Child Support in Arrears (total balance) Back Taxes Owed (total balance) Public Records (not including Child Support Arrears and Back Taxes) TOTAL LIABILITIES NET WORTH Total Assets Total Liabilities Total Unpaid Bills (not in collections) Total Collections/Judgments TOTAL NET WORTH

7 FFT Combined Financial Assessment (CFA) BASELINE PROFILE Name: Date profile completed/updated: Section A. Household Composition A-2 FFT How many in household (include yourself)? A household includes 1) one or more heads of household, and 2) their dependents (people for whom they are financially responsible). A-3 FFT Living Arrangement: House/Apt is owned by household member House/Apt is rented by household member, subsidized House/Apt is rented by household member, unsubsidized Household stays in the House/Apt for free Household is homeless (without a roof) or in a shelter A-4 Number of OTHER household members 18 years or older (do not include yourself in count): A-5 Please complete the table below for all OTHER household members 18 years or older (do NOT complete for yourself). Section B. Adult 1 Section C. Adult 2 Age Is this person working now? In the past 12 months, how many full months did this person work? How much earned income (after tax) for this person in the past 12 months? Section D. Adult 3 Section E. Adult 4, Adult 5, Adult 6, etc. E-1 For Adult 4, Adult 5, Adult 6, etc, how much earned income (after tax) in the past 12 months? Section F. Products/Practices (circle one) F-1 Do you have a budget (a written spending plan) for all your monthly expenses? Yes No F-2 Over the past three months, have you been able to pay your bills on time? Yes No F-3 Over the past three months, have you had to borrow from friends or family to pay for basic necessities like food or rent? Yes No F-4 Do you presently have a checking account with a bank or credit union? Yes No F-5 Do you bounce checks frequently (at least once a month for the past three months)? Yes No F-6 Have you ever had a checking account? Yes No F-7 What is the main reason for not having one? in ChexSystems don t like dealing with bank personnel not sure how to set one up fees too high not enough money to make account useful transactions take too long other F-8 Do you presently have a savings account with a bank or credit union? Yes No F-9 Do you set aside money for savings on a regular basis? Yes No F-10 Do you presently have one or more active credit cards? Yes No F-11 Over the past three months, have you paid the minimum owed on all your cards paid the entire balance on all your cards paid less than the minimum, or nothing paid more than the minimum, but not the entire balance F-12 Have you ever had a credit card? Yes No Page 1 of 2

8 F-13 Are you in a Debt Management Plan or working with a Debt Settlement or Credit Repair company? Yes No F-14 Did you file a tax return in the last tax season? Yes No F-15 Health Insurance Status (primary insurance only) private insurance through a household member s employer insured through government program private insurance (not through a household member s employer) no insurance at all Section G. Red Flags (circle one) G-1 Have your wages been garnished in the past year, or are you in danger of having your wages garnished? Yes No G-2 Are you in bankruptcy now (i.e. your debt has not yet been fully discharged), or are you in the process of filing for bankruptcy? Yes No G-3 If your household rents, have you been evicted in the last year, or are you in danger of being evicted? Yes No N/A G-4 If your household owns, has your mortgage lender started foreclosure proceedings against you? Yes No N/A G-5 Have any of your utilities been disconnected in the past year, or are you presently in danger of having your utilities disconnected? Yes No G-6 Has your car(s) been repossessed in the past year, or is it presently in danger of being repossessed? Yes No N/A G-7 Are collection agencies presently contacting you about unsettled claims? Yes No Section H. Baseline Profile Notes H-1 Notes Page 2 of 2

9 Credit Release Authorization To assist [Wesley Community Center, Inc. of Houston, Texas ( WCC ) in its ability to provide me with financial counseling services, I hereby authorize WCC to pull my Transunion credit report and FICO score now and periodically, but not more frequently than once every six (6) months for a period not to exceed five (5) years from the date of this authorization. I understand that all inquiries by WCC into my credit constitute soft inquiries and will not adversely affect my credit or my credit rating. While the credit reports and scores pulled by WCC on my behalf will be used to provide me with financial counseling and/or to track my financial outcomes, it is understood that I will not receive a copy of the credit reports. I understand that I may request a financial counseling session at WCC in the future to discuss information in any credit report and/or credit score pulled by WCC on my behalf. I further understand that I may withdraw WCC authorization to pull additional credit reports or credit scores at any time without penalty. Not withstanding the foregoing, I understand that I have the right to dispute information with the credit bureau, to request reinvestigation, and to have corrected reports reissued to previous recipients of the credit report at issue. I understand that credit information is sensitive and that there may be inherent risks to accessing such data; I have had the opportunity to ask (financial counselor): questions regarding such risks. I understand that all of my personal information will be held confidential by WCC and used only as authorized by me. Any questions that I may have regarding the above will be answered by (financial counselor) at WCC. Client s name Date:

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11 Wesley Community Center, Inc. of Houston, Texas Consent Form for Research Wesley Community Center helps participants become more financially secure by assisting them to get and keep jobs, enter and complete training, access public benefits for which they are eligible, and learn how to manage their money. The Local Initiatives Support Corporation (LISC), one of the organizations funding these activities at Wesley Community has asked three research groups, Project Match, Abt Associates Inc., and Economic Mobility Corporation, Inc. to figure out which kinds of assistance and supports are helpful to participants and which ones are not. They are doing this research to help Wesley Community Center become a stronger agency and to help similar groups around the country learn from their experience. To be part of this research, you may be asked to fill out a survey from time to time, participate in a focus group, or be interviewed about your work, school, and finances. than that, you do not have to do anything different from what you would normally do as a Wesley Community Center participant. The information that you give to staff, or that you authorize staff to access (including information regarding your credit history and credit score) is the same information the researchers will use to do their work. That information may include your program application, as well as records on the services you have received and the goals you have met. At some point, researchers might ask a government agency about your earnings from work and any public benefits you have received, such as TANF or Medicaid. Your Right to Confidentiality All the information you provide to Wesley Community Center, and the research organizations Project Match, Abt Associates Inc., and Mobility Corporation, Inc. is completely confidential. In research reports and presentations, your privacy will always be respected and your name or other personal information that might identify you will never be used. Benefits and Risks There are no special benefits or risks to you as an individual if you participate in this research; the information will be used only for learning purposes, so that programs know the kinds of assistance and supports that help people become more financially secure. Participation in this research study is completely voluntary. If you do not want to participate in the research, you can still continue to receive the same services and supports. Also, if you choose to participate in the research, you may discontinue participation at any time without penalty. Yes, I have read this form and agree to participate in the research conducted by Project Match, Abt Associates Inc. and Economic Mobility Corporation, Inc. No, I have read this form and have decided not to agree to participate in the research conducted by Project Match, Abt Associates Inc., and Economic Mobility Corporation, Inc. If you have any questions regarding this research or your rights, please contact: Program Officer Charles Chang Ann St. George Anne Roder Berenice Tostado Local InitiativesSupport Corporation Research Associate Project Match Associate Abt Associates Inc. Economic Mobility Corporation, Inc N. Loop West, Ste N. LaSalle St. 55 Wheeler St. 233 Broadway, 12 th Floor Houston, TX Chicago, IL Cambridge, MA New York, NY (312) (617) (212) Your name (please print) Your signature Wesley Community Center staff signature Today s date

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13 AUTHORIZATION FOR VERIFICATION OF EMPLOYMENT I hereby give my permission for the release of confidential information concerning my employment to Wesley Community Center. Employee Name (Please Print) Employee Social Security No. X Employee Signature Date (To Be Filled Out By Employer) Please provide the following information: Name of Company: Address: Telephone#: Position Held: Date of Employment: Date of Termination: Rate of Gross Pay Hourly Weekly Monthly Overtime Hours (if regularly scheduled): Hours Scheduled Per Week Name & Title of Person Providing Information Contact number Date PLEASE FAX BACK TO: WESLEY COMMUNITY CENTER/ ATTN: Goga Dvorscak ADDRESS: 1410 Lee St. Houston, TX PH: ( 713 ) FAX: ( 713 )