Household Willingness-to-Pay Assessment Form
Household Information
Household Head Name
Contact Number
Address
Household Size
Socio-Economic Information
Estimated Monthly Income
Main Source of Income
Service Details
Current Service Accessed
Level of Satisfaction
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Monthly Spending on Service
Willingness to Pay for Improved Service
Reason for Willingness/Unwillingness to Pay
Additional Comments