Family Financial Support — Nonprofit Financial Education

Household Financial Wellness Survey

This survey helps us understand your household's current financial picture. It is designed to be simple, respectful, and easy to complete. Please answer as accurately as possible so we can better understand your needs.

Take your time. Your answers help us better understand your household needs.

Section 1: Applicant Information

First Name

Last Name

Email Address

Phone Number

Preferred Contact Method

Best Time to Contact

Street Address

City

State

ZIP Code

Are you currently the head of household?

Yes

Section 2: Household Information

Total number of people in household

Housing status

Do you have any elderly household members?

Yes

Section 3: Employment & Income

Please enter your best monthly estimate. Estimates are okay if you do not know the exact amount.

Current employment status

Total estimated monthly household income

Section 4: Current Hardship

This section helps us understand what your household is currently facing. Please share what you are comfortable sharing.

What hardship are you currently experiencing? (Select all that apply)

Job loss

Reduced work hours

Medical emergency

Eviction risk

Utility shutoff notice

Food insecurity

Unexpected emergency expense

Debt burden

Briefly describe your current hardship

Are you at risk of losing housing within the next 30 days?

Yes

Are you at risk of utility shutoff within the next 30 days?

Yes

I understand that submitting a grant application does not guarantee approval and grant assistance is based on region, eligibility, available documentation, and review criteria.

I authorize TJFF and its agents to review my application and contact me at the phone number(s) and email address provided regarding my request and related offers, including via live calls, automated/autodialed calls, prerecorded or artificial voice messages, SMS/MMS text messages, email, and mail. I understand message and data rates may apply, consent is not a condition of any purchase, and I may revoke consent at any time by replying STOP or contacting our client care department.