CHOICE42 FINANCIAL QUESTIONNAIRE

This Questionnaire and at least two financial meetings are required to be considered for any financial assistance.

The type and amount of assistance will be determined on a case-by-case basis and we may deny any request without reason.

*THIS FORM IS FOR INDIVIDUAL USE ONLY - DO NOT SHARE OR COPY THIS FORM IN ANY WAY.

Name

First Name

Last Name

Do you belong to a local church? If yes, please provide the name and contact (email or phone number) for the pastor or an elder.

What is your living situation? Who lives in the household? What is the plan when baby comes?

Are you receiving any financial assistance currently (or within the last 90 days). Include help from family, government agencies, churches and other organizations.

ASSETS

Please list all bank accounts you have along with average monthly balance. Include any retirement accounts and investments if applicable. (Example: M&T $300 average). Most recent statement required for each.

What non-monetary assets do you own? (Example: real estate, precious metals, vehicles, etc.)

INCOME

Current Employer or Source of Primary Income:

How much is your MONTHLY NET income (this means the amount that actually gets deposited to your bank account AFTER all the taxes and other amounts have already been deducted) from this income source? You will need to provide your most recent paystub. Please also include the TOTAL NET INCOME FOR YOUR HOUSEHOLD.

If you have another source of income, please describe here where it is coming from and how much per month (you will need to provide documentation).

LIABILITIES (Debts and Payments)

Please list EVERY loan or credit card here. Make sure you include what is your balance owed, how much must you pay each month and IF your payments are CURRENT right now or if you’re behind. (Example: Capital One Credit Card Payment $35, balance $500, current). Recent statement required for each one.

Monthly Housing Cost (Mortgage or rent payment amount if not listed above). Statement or lease agreement is required.

Monthly cost for phone (cell, landline, etc), internet and TV (combine all together). Most recent bill required for each.

Monthly Utilities Expense (Gas + Electricity + water, etc). Most recent bill for each required.

Childcare costs per month (if applicable). Childcare agreement required.

How much do you spend monthly on groceries?

Do you have monthly car payments and insurance? How much do you spend monthly on gas for your car or on transportation in general?

How much do you spend monthly on clothing?

How much do you spend monthly on “wants” (things you don’t need like fast food, toys, makeup, etc.)

Is there any other payment that you have that we haven’t covered yet? List all the details here and provide us with documentation.

REQUESTS

Explain the type of assistance you are looking for.

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IMPORTANT!

Please understand that you are required to attend a minimum of two financial meetings with a member of our finance team. These meetings will take place virtually via ZOOM. All assignments given must be completed to be considered for any financial assistance. No decision is made during your finance meetings as to whether or not we will be helping you monetarily. Your case will be presented to our finance team for evaluation after you've completed the second meeting. Please notify us at least 24 hours in advance if you cannot attend your meeting for any reason. Know that missing your meeting will put your file to the end of the line and it may take time before it can be rescheduled.
Between the first and second meeting you are required to track all spending using either a spending app or just pen and paper. This will help you to discover ways in which your spending should change in order to have more for the things you truly need.
Please review the Needs vs. Wants Pyramid below as it will be discussed in your first meeting.
Please email all documentation to your assigned finance team member approximately 24 hours prior to your meeting so they have time to review your situation.

CHOICE42 Financial Questionnaire

CHOICE42 FINANCIAL QUESTIONNAIRE

*THIS FORM IS FOR INDIVIDUAL USE ONLY - DO NOT SHARE OR COPY THIS FORM IN ANY WAY.

IMPORTANT!

We thank you for your honestly, and we look forward to speaking with you during your financial meetings.