# Financial Assessment

OMB Control Number: 3170

- 00xx

Expiration Date:



# Contents 

Demographics

Client Info

Disability Questions

Socioeconomic

Income & Benefits

Employment

Education

Income & Debt

Credit Report and Score

Tax Filing

Consumer Protection/Consumer Rights

Housing

Financial C apability

Banking & Savings Questions

Decision

- making , Attitudes and Behavior Questions

Questions Specific to Clients to opt for Coaching 

### 



## Demographics

Client Info

1. First Name

2. Middle Initial

3. Last Name

4. Street Address and Zip

5. Email

6. Primary Phone

7. DOB



### 8. Gender (expression of identity)



### 9. Ethnicity:

1. Hispanic or Latino

### 2. Not Hispanic or Latino

10. Race

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Other

11. Nativity

1. US Born, Foreign born (Naturalized) US citizen, Foreign born non

- citizen

12. Marital Status

1. Single, Married, Widowed, Separated, Divorced, Domestic Partner, Common Law

13. Language Preference

1. List for selection

14. Highest level of Education completed

1. List for selection (some HS through more than college)

15. Do you or a family member living in your household have a disability?

1. Yes = myself

2. Other = another fami ly member has a disability

3. Both = myself and at least one other family member

4. No = No disability present

16. If yes, or other, w hat t ype of Disability do you or does someone else in your household have ?

1. Permanent Mobility and Physical Impairments, including sp inal Cord Disability; Head

injuries

- Disabilities such as Acquired Brain injury or Traumatic Brain Injury,

2. Vision

3. Hearing

4. cognitive or learning disabilities

5. psychological disorders

6. intellectual or developmental disability

7. Other

17. Are you or a family member affiliated with the US Armed Forces? (Self, member of the immediate

family)

1. Retiree

2. V eteran

3. Reserves

4. Active

- duty

1. Air Force

2. Army

3. Navy

4. Marine Corps

5. Coast Guard

18. Are you a student taking courses for credit?

1. Part

- time

2. Full

- time

3. Four

- year college or university

4. Two

- year community colleges

5. Vocational, technical, or trade school

6. Other

19. How did you hear about this program?



### Disability Questions1. Is there a specific accommodation that you need to participate in the counseling/coaching

services offered? One

- o n

- one or group class?

1. Yes

1. American Sign Language Interpreter

2. Assistive Technology Devices

3. Large Print

4. Braille

5. Microphone

6. Screen Reader

7. Others?

2. No

1. Are you an active Vocational Rehabilitation Client?

2. Are you registered for services with the Workforce Investment System?



## Socioeconomic

Income & Benefits

1. Do you receive WIC?

1. Eligibility unknown

2. Not eligible

3. Eligible, but have not applied

4. Application in process

5. Receiving benefit

2. Do you receive SNAP ( food stamps )?

1. Eligibility unknown

2. Not eligible

3. Eligible, but have not applied

4. Application in process

5. Receiving benefit

3. Do you receive TANF ?

1. Eligibility unknown

2. Not eligible

3. Eligible, but have not applied

4. Application in process

5. Receiving benefit

4. Current income sources and amounts

1. Total monthly non

- cash benefits amount

1. Family Medicaid and Individual Medicaid

2. Food Stamps

3. Section 8 vouchers

4. Energy Assistance

5. Rental Assistance

6. State Child Health Insurance Program

7. Special Needs Trust

8. Pooled Trust

9. State waivers

10. Social Security Pension

11. Other

2. Total mont hly cash benefits/income amount

1. Child support

2. Earned income

3. General assistance

4. Social Security Disability Income (SSDI)5. Supplemental Security Income (SSI)

6. Temporary Assistance for Needy Families (TANF)

7. Unemployment insurance

8. Other

5. Household composition

1. Number of Adults 18 or over in Household

2. Number of Children under 18 in Household

3. Number of Children in Household at least 50% financially dependent on you



### Employment

1. Employment situation

1. No job, not actively searching

2. No job; cannot work

- temporary ( e.g. new baby, full

- time education )

, 3. No job; cannot work

– permanent (e.g. permanent disability, retired)

4. No job and capable of working with my disability, but putting little effort into search

5. No job and capable of working with my disability but afraid to work because I could lose

my benefits

6. No job but actively searching

7. Employed, dissatisfied

8. Employed, satisfied

2. Are you currently receiving support in your employment search? Yes/No

1. If answered yes, then from which agency /organization ?

Each of the below employment questions should be conditional upon these responses above:

• “employed

– dissatisfied”

• “employed

– satisfied”

3. Employer type details

4. Hourly pay

5. Number of hours worked per week, on average

6. Paid leave (Y/N)

7. Current employee benefits

1. Health insurance

2. 401K

3. Life Insurance

4. Other

5. Employed since (date)

Each of the below employment questions should be conditional upon these responses above:

• “No job and capable of working with my disability, but putting little effort into search”,

• “No job and capable of working with my disability but afraid to work because I could lose by benefits”

• “No job but actively searching”

3. Unemployed since (date)

4. Are you aware of Social Security Administration Work Incentive counseling services with return to

work focus?

1. Yes

2. No

3. Would like to know more

### Education

1. What, if any, educational path is participant pursuing?

1. None

2. HS/GED

3. College

4. Vocational certificate

Each of the below education questions should be conditional upon the appropriate responses above:

2. HS/GED progress

1. Not enrolled

2. Enrolled and in danger of dropping out

3. Enrolled and on track to completing

4. Obtained HS diploma/GED

3. College progress

1. Not enrolled

2. Enrolled and in danger of dropping out

3. Enrolled and on track to completing

4. Obtained 2

- year college diploma

5. Obtained 4

- year college diploma

4. Vocational certificate progress

1. Not enrolled

2. Enrolled and in danger of dropping out

3. Enrolled and on track to completing

4. Obtained vocational certifica te



### Income , Assets and & Debt

1. Total monthly income

2. Do you own any or all of the following a sset s (list, choose all that apply ; measure neither increase

nor decrease)

1. Home

2. Car

3. Other

3. What is your r ecurring monthly debt amount?

4. Please list the following types of debt you currently have:

1. S tudent loan debt?

2. Credit card/consumer loan

3. Assistive Technology or Durable Medical Equipment Loan

4. Mortgage

5. What describes your current state of thinking regarding paying off your debt?

1. Not thinking about paying

- off debts

2. Thinking about paying

- off debts

3. Actively making a plan to pay

- off debts

4. Making regular payments to reduce consumer debt

5. Pays

- off consumer debt monthly, makes regular payments on larger debt like mortgage

and student loans

### Credit Report and Score

1. How would you describe your use of credit?

1. D on’t have any credit cards or loans outstanding.

2. H ave one or more credit card accounts, but pay them off in full every month.

3. C arry balances on my credit cards from month to month.

4. M ake the minimum payment on my credit cards.

5. M axed out on my credit card accounts so use them sparingly to make purchases.

2. Consumer report (credit report) status

1. Unknown never pulled

2. Unknown, not recently pulled

3. Incorrect information on credit report

– no action taken

4. Incorrect information on credit report

– actions taken to correct it

5. Correct

3. If answered “Unknown”, why has the participant never pulled his/her credit report?

1. Wasn’t interested

2. Couldn’t

3. Don’t know how



### 4. Didn’t understand previously pulled report”

5. 

### Didn’t know benefits of obtaining a report in the past

4. If answered “incorrect” or “correct”, how often does the participant review his/her credit record?

1. Infrequently

– once or twice total

2. Frequently

– every few years

3. Regularly

– every 12 months or more

5. What do y ou believe is your current credit score ?

1. Very high (750

- 850)

2. High (700

- 749)

3. Middle (660

- 699)

4. Somewhat Low (620

- 659)

5. Very Low (340

- 619)

6. Don’t Know/Don’t have a Credit Score

6. How sure are you of this score?

1. Very Sure

2. Sure

3. Unsure

4. Very Unsure

5. Don’t Know/Don’t h ave a Credit Score

7. Most recent credit report, score and date

— Note: Would you like to review a copy of your credit report and score now? If yes, you have an

option to share your social security number so we may get your credit report and score for you, or

you may access your own credit report at www.annualcreditreport.com

. Providing your Social

Security number is voluntary however if you do not provide the SSN we will not be able to retrieve

your credit r eport and score.

### Tax Filing

1. Did you file your income t axes? (Yes, No)

1. 2011

2. 2012

3. 2013

4. 2014

5. 2015

6. 2016

7. 2017

8. 2018

9. 2019

2. Do you have access to free tax assistance?

1. Yes

2. No

3. I don’t know

3. Have you ever claimed the Earned Income Tax credit?

1. Yes

2. No

3. I don’t know

4. If you filed a tax return in the past or this year did you use:

1. Free In Person Service

2. Filed Taxes Online for Free

3. Friend or Family prepared them for me

4. Paid to file Taxes online

5. Paid preparer

6. Self

- prepared via paper forms



### Consumer Protection/Consume r Rights

1. Have you ever experienced financial abuse? ( Do you know or believe there was illegal or

improper use of your money against your will?)

1. Yes

2. No

2. If yes, do you know where to go to report the abuse?

1. Yes

2. No

3. Are you currently experiencing a problem with a consumer financial product or service?

1. Yes

2. No

4. Are you currently being contacted by a debt collector?

5. Would you like to learn how to submit a complaint to the Consumer Financial Protection Bureau?

1. Yes

2. No

6. Do you know the steps you should take to protect your identify?

1. Yes

2. No

### Housing

1. Housing Situation Descriptions (which is the best description of your housing situation?)

1. Homeless

– the individual/family has no place to live, is squatting or living out of doors

2. Living in temporary/transitional housing

– the individual/family has no permanent place to

live, is living in a shelter or transitional residential program

3. Living in permanent but sub

- standard housing

– the individual/family is living in own ed or

a rented space, may not be able to afford what it costs to maintain this situation, and

conditions are overcrowded, unsafe, or otherwise unsatisfactory and may not be fully

accessible for tenant with mobility issue etc.

4. Living in permanent, appropriate housing

– the individual/family is living it its own or a

rented space, can afford to maintain this situation, and conditions are safe and

satisfactory

5. Living in Group Housing

– the individual is living on its own in rented space with XXX

other people with disabilities.

1. How many other persons with d isabilities are living in the same house?



## Financial Capability

Banking & Savings Questions

1. Which of the following best describes your household’s finances?

1. The adults have shared finances

2. The adults have some shared finances and some separate finances

3. The adults have separate finances even though we share living space

4. I am the only adult in the household

5. DK/Refused

2. How much do you participate in making financial decisions for your household?

1. A lot

2. Some

3. Not at all

4. DK/Refused

3. Do you or does anyon e in your household currently have a checking or savings account?

1. Yes

2. No

3. DK/Refused

4. What type or types of accounts do you or family members currently have?

1. Only checking account

2. Only savings account

3. Both checking and savings accounts

4. Other

5. DK/Refused

5. In the past 12 months have you or anyone in your household used any of the following methods

to access an account?

1. Bank teller

2. ATM/Kiosk

3. Telephone banking through phone call or automated voice/touch tone4. Online banking through desktop, laptop, or tablet computer (e.g, IPad)

5. Mobile Banking through text messaging, mobile apps, or Internet browser or email on

phone

6. Other

7. Did not access an account in the past 12 months

8. Don’t Know/Refused

6. Are you or member of your household enrolled in IDA or other s avings program?

1. Yes

2. No

7. Amount of monthly living expenses

8. Amount of total emergency savings

9. Amount of Savings

– months of living expenses

10. Saving regularly

– stage of change

1. Not Saving

2. Thinking about saving

3. Preparation

4. Action

5. Maintenance

11. Have you u sed these alternative loan/alternative financial services at least once? (past month, six

months, year, more than a year, never)

1. Check Cashing

2. Money order

3. Remittance

4. Payday Loan

5. Rent

- to

- own

6. Pawn Shop

7. Refund

- Anticipation

- Loan



### Financial Decision

- making

, Attitudes and Behavior questions

1. Over the last 3 months, have you followed a personal budget, spending plan, or financial plan?

1. Yes

2. No

3. Don’t know

2. Do you currently have a least one financial goal?

1. Yes, I have a one or more goal(s) to (check all that apply)

1. Create a plan to use a budget

2. Reduce existing expenses

3. Increase savings

4. Increase income

5. Improve credit score

6. Establish/build credit

7. Pay bills

8. Reduce Debt

9. Access Assistive Technology Loan Fund

10. Access financial products/services

11. Access mortgage lending services

12. Access small business lending resources

2. No, I do not have a financial goal.

3. How confident are you in your ability to achieve a financial goal you set for yourself today?

1. Not at all confident

2. Less than confident

3. Somewhat confident

4. Relativel y confident5. Very confident

4. In the last 3 months, did you use an automatic deposit or transfer to put money away for a future

use such as saving for retirement or education?

1. Yes

2. No

3. Don’t Know

5. In the last 3 months, did you manually deposit a cash, chec k or other to put money away for a

future use such as saving for retirement or education?

1. Yes

2. No

3. Don’t Know

6. Have you set aside emergency or rainy day funds that would cover your expenses for 3 months,

in case of sickness, job loss, economic downturn or oth er emergencies?

1. Yes

2. No

3. Don’t Know

7. Over the past 3 months, would you say your household’s spending was less than, more than or

about equal to your income? Please do not include large , one

- time purchases such as a house or

car.

1. Less than

2. More than

3. Equal to

4. Don’t know

8. Over the past 3 months, would you say your household’s savings was less than, more than or

about equal to your income?

1. Less than

2. More than

3. Equal to

4. Don’t know

9. In the last 3 months, have you paid a late fee on a loan or bill?

1. Yes

2. No

3. Don’t Know

10. Thinking about big things that people buy, such as furniture, a refrigerator, an automobile, a

television and things like that, do you think it would be:

1. An excellent time to buy

2. A good time to buy

3. Only a fair time

4. A poor time to buy

11. Would you say y our own personal finance situation is better now, worse now or about the same

as it was a year ago?

1. Better than a year ago

2. Same as a year ago

3. Worse than a year ago

12. Here are some ways people manage the way they spend and save. Which of these steps have

you taken in the last year?

1. Cut down on credit card purchases

2. Paid down debt/reduced the amount of money you owe

3. Taken on another credit card

4. Taken out additional loans/borrowed money

5. Postponed the purchase of a major item like an automobile or furniture

6. Taken money out of savings to cover living expenses

7. Sold car or house or other big item

8. Changed living arrangements in order to save money

9. Worked longer hours or taken a second job to earn more money

10. Postponed retirement11. Put more purchases on your credit card so you didn’t have to pay for things immediately

12. Made minimum payments on credit cards rather than paying them off immediately

13. Cut down on non

- essential spending like restaurants or vacations

14. Cut back on premium products like coffee shops or expensive food bought less

expensive options

15. Shopped more at discount stores and warehouse clubs

16. Use layaway to make big purchases



### Financial Attitudes and Behaviors (FINRA)

1. Do you feel better, worse or the same about your financial status compared to six months ago?

2. How would you describe your savings now when compared to six months ago, better, worse or

the same?

3. How would you describe your debt now when compared to six months ago, better, worse or the

same?

4. In a typical month, how difficult is it for you to cover your expenses and pay all your bills?

1. Very difficult

2. Somewhat difficult

3. Not at all difficult

4. Don’t know

5. Prefer not to say

5. Have you set aside any money for after high school education or other training for you or your

children?

1. Yes

2. No

3. Don’t Know

4. Prefer not to say

6. Have you ever tried to figure out how much you need to save for retirement?

1. Yes

2. No

3. Don’t know

4. Prefer not to say

7. Has your household experienced a large drop in income which you did not expect?

1. Yes

2. No

3. Don’t know

4. Prefer not to say

8. How confident are you that you could come up with $2000 if an unexpected need arose within the

next month?

1. I am certain I would come up with the full $2000

2. I could probably come up with $200 0

3. I could probably not come up with $2000

4. I am certain I could no t come up with $2000

5. Don’t know

6. Prefer not to say

9. In the last 5 years have you asked for any advice from a financial professional about any of the

following?

1. Debt counseling

2. Savings or investment

3. Taking out a mortgage or a loan

4. Insurance of any type

5. Tax pl anning

10. Do you take care of your own financial business?

1. Yes

2. No11. Does someone assist you with your finances?

1. Yes

2. No



## Questions Specific to Clients to opt for Coaching

1. Is there a specific accommodation that you need to participate in the coaching or counseling

services offered?

1. Yes

1. American Sign Language Interpreter

2. Assistive Technology Speaking Device

3. Large Print

4. Braille

5. Microphone

6. Screen Reader

7. Others?

2. No

2. Do you have a financial goal (s) that requires long

- term savings or investment?

1. Yes

2. No

3. Don’t Know

4. Refused

5. Not applicable

3. What will you use your long

- term savings/investment for?

1. Motor Vehicle

2. Motor Vehicle Modification

3. Home

4. Home Improvement/Modification

5. Small Business Development

6. Investment Account

7. Retirement

8. Education

9. Mobility Related Purchase (wheelchair, assistive technology, etc.)

10. Other __________

4. What other uses might you use this long

- term savings for?

1. To travel back and forth to work

2. To improve access to employment opportunities

3. To improve mobility and/or sensory or cognitive functioning (purchase of new wheelchair,

Braille reader, VRS phone, prostheses, AT, etc. rehabilitation services/procedures not

covered by insurance)

4. To improve accessibilit y to apartment or home

5. To build an employment opportunity for myself

6. To prepare for my retirement

7. To take a course to improve job skills

5. Have you created a plan to achieve your goal?

1. Yes

2. No

3. Don’t Know

4. Refused

5. Not applicable

6. What is your target date for achieving goal?

1. 0

- 3 Months

2. 3

- 6 Months

3. 6

- 12 Months

4. 1

- 2 Years5. 3

- 5 Years

6. 5

- 10 Years

7. More than 10 Years

7. What areas can the coach assist you with to achieve this goal?

1. Create a plan to use a budget

2. Reduce existing expenses

3. Increase savings

4. Improv e credit score

5. Establish/build credit

6. Reduce Debt

7. Access Assistive Technology Loan Fund

8. Access financial products/services

9. Access mortgage lending services

10. Access small business lending resources

8. What goal achieved?

1. Yes

2. No

3. In Progress

9. What goal was achieved?

____________ 10. What percentage is complete? (Enter a percentage (20%, 30%, etc. )



### Self

- Sufficiency Matrix (for use with clients who opt

- in to coaching)

Domain 1 2 3 4 5

Housing Homeless or threatened with

eviction. In transitional, temporary or

substandard housing; and/or

current rent/mortgage payment is

unaffordable (over 30% of

income). In stable housing that is

safe but only marginally

adequate. Household is in safe, adequate

subsidized housing. Household is safe,

adequate, unsubsidiz

housing.

Employme

nt No job. Temporary, part

- time or

seasonal; inadequate pay, no

benefits. Employed full time;

inadequate pay; few or no

benefits. Employed full time with adequate

pay and benefits. Maintains permanen

employment with

adequate income an

benefits.

Income No income. Inadequate income and/or

spontaneous or inappropriate

spending. Can meet basic needs with

subsidy; appropriate

spending. Can meet basic needs and manage

debt without assistance. Income is sufficient, w

managed; has

discretionary income

is able to save.

Food No food or means to prepare

it. Relies to a significant degree

on other sources of free or

low

- cost food. Household is on food stamps. Can meet basic food needs,

but requires occasional

assistance. Can meet basic food needs without

assistance. Can choo se to purcha

any food household

desires.

Child Care Needs childcare, but none is

available/accessible and/or

child is not eligible. Childcare is unreliable or

unaffordable, inadequate

supervision is a problem for

childcare that is available. Affordable subsidized

childcare is available,

but limited. Reliable, affordable childcare is

available, no need for subsidies. Able to select quality

childcare of choice.

Adult

Education Literacy problems and/or no

high school diploma/GED are

serious barriers to

employment. Enrolled in literacy and/or GED

program and/or has sufficient

command of English to where

language is not a barrier to

employment. Has high school

diploma/GED. Needs additional education/training

to improve employment situation

and/or to resolve literacy problems

to where they are able to function

effectively in society. Has compl

education/training

needed to bec

employable. No lite

problems.

Health Care

Coverage No medical coverage with

immediate need. No medical coverage and great

difficulty accessing medical care

when needed. Some household

members may be in poor health. Some members (e.g.

Children) have medical

coverage. All members ca n get medical care

when needed, but may strain

budget. All members are cove

by affordable, adequ

health insurance.Domain 1 2 3 4 5

Mobility No access to transportation, public

or private; may have car that is

inoperable. Transportation is available, but

unreliable, unpredictable,

unaffordable; may have care but

no insurance, license, etc. Transportation is available and

reliable, but limited and/or

inconvenient; drivers are

licensed and minimally insured. Transportation is generally

accessible to meet basic

travel needs. Transportation is read

available and afforda

car is adequately insu

Community

Involvement Not applicable due to crisis

situation; in “survival” mode. Socially isolated and/or no social

skills and/or lacks motivation to

become involved. Lacks knowledge of ways to

become involved. Some community

involvement (advisory

group, support group), but

has barriers such as

transportation, childcare

issues. Actively involved in

community.

Safety Home or residence is not safe;

immediate level of lethality is

extremely high; possible CPS

involvement. Safety is

threatened/temporary

protection is available; level of

lethality is high. Current level of safety is

minimally adequate; ongoing

safety planning is essential. Environment is safe,

however, future of such is

uncertain; safety planning

is important. Environment is appar

safe and s table.