Low-Income Family Needs Survey
Full Name
Address
Phone Number
Email
Household Information
Number of people in household
Number of children (under 18)
Number of adults (18 and over)
Income & Employment
Employment Status
Employed Full-time
Employed Part-time
Unemployed
Looking for Work
Unable to Work
Total Monthly Household Income
Current Needs
Food Assistance Needed
Yes
No
Housing Assistance Needed
Yes
No
Utility Assistance Needed
Yes
No
Medical or Healthcare Assistance
Yes
No
Other Needs