Adult Program Pilot

OMB Control #1505-XXXX

SURVEY ABOUT FINANCES

BACKGROUND INFORMATION

1. Last Name:	2. First Name:	3. Date of Birth:
4. Are you of Hispanic or Latino origin? Yes No Prefer not to answer 5. Race: (select one or more) White Black/African-American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native Prefer not to answer	6. Living Situation: Rent Own Staying with family/friends Public housing Homeless/shelter Prefer not to answer	7. Marital Status: Married Single (never married) Divorced/Separated Widowed Prefer not to answer
	8. How many adults (18 and over), including yourself, are in your household? ____________	9. How many children (under 18) are in your household? ____________

USE OF FINANCIAL SERVICES

10. Did you have a bank account in the month before starting POP?		11. If you did not have a bank account in the month before starting POP, did you have one in the past? Yes No 11a. IF YES, why did you close it? (check all that apply) I could not maintain the minimum balance Fees were too high I don’t like dealing with banks I don’t trust banks I had a negative experience with my bank I have judgments/liens It was frozen / garnished Other reason: _________________________________ ________________________________________________ 11b. IF NO, why don’t you have a bank account? (check all) I can’t maintain the minimum balance Fees are too high I tried but bank denied me I don’t have the required identification I don’t like dealing with banks I don’t trust banks I had a negative experience with my bank I have judgments / liens I don’t want my wages garnished Other reason: _________________________________ ________________________________________________
No account	Yes, savings account
Yes, checking account	Yes, both checking and savings account
12. Did you have any of the following in the month before starting POP? (check all that apply) Prepaid card Payroll card EBT/Public Benefits card Direct deposit to bank account Direct deposit to payroll card
13. Have you used any of the following in the last month? (check all that apply) Check-cashers Money orders Online bill pay Pay day lender Pawn shops

FINANCIAL INFORMATION

14. If you had an unexpected expense or emergency of $500, how confident are you that you could pay it? Not at all A little Somewhat Very Extremely	15. Do you use a budget or spending plan? Yes No	16. Have you viewed your credit report in the past 12 months? Yes No
	17. Are you saving regularly? Yes No 18. Do you have any savings? Yes No		19. If you have savings, about how much money do you have saved? $_______________
20. About how often do you contribute to savings? Weekly Every two weeks Monthly Several times a year Once per year Less than once per year Never, do not contribute to savings	21. How often is your household able to pay all bills, such as rent /mortgage, utilities, food, etc? Almost always Often Sometimes Rarely Never			22. Do you trust banks? Not at all A little Somewhat Very Extremely
23. How much control do you feel over your finances? No control A little control In control Very in control Extremely in control	24. How would you rate your understanding of money-management? Very bad Poor Fair Good Excellent			25. How frequently do you pay your bills on time? Almost always Often Sometimes Rarely Never

Paperwork Reduction Act Notice

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number. The estimated time to complete this survey is 20 minutes. To provide comment on this survey, please contact Louisa M. Quittman, Director, Community Programs, Office of Financial Education and Financial Access, US Department of the Treasury, 1500 Pennsylvania Ave., NW, Washington, DC 20220. This is an approved information collection under OMB #1505-XXXX