Form 3170-XXXX Application Survey & Script

Script for Completing the Application Survey
At this point, we would like you to complete our program application survey that will help us understand the
characteristics of people who are interested in financial coaching. The survey will take approximately 10 minutes.
Completing the application form is voluntary. It is possible that you may find some of the survey questions to be
personal; however, your information will be kept private and will help us to understand your financial background.
Please remember that the information that we collect in the application form and in the later outcomes survey will be
kept private. This information will be combined with information from all other study participants and will not be
reported or shared in a way that would allow anyone to link what you tell us with who you are. We will not publish your
name or other personal identifying information in anything we write or talk about. We also will not share information
that identifies you, including your name or information from your credit report, with anyone outside of the research
team, including the Consumer Financial Protection Bureau. All of your answers will be stored in databases with secured
password protection and accessed only by research staff who are committed to ensuring your privacy, and who have
signed data privacy pledges.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
the collection of information displays a valid control number assigned by the Office of Management and Budget
(OMB). The OMB control number for this collection is 3170–XXXX. The collection expires on XX/XX/XXXX. Also, a federal
law called the Privacy Act directs how the federal government treats the personally identifiable information contained in
your answers to these questions. To understand how and when your personally identifiable information may be shared,
you can read the Privacy Act Statement on the CFPB’s website at www.consumerfinance.gov and search for CFPB.021
Consumer Education and Engagement Records. Additionally, the CFPB will treat the information received from you
consistent with its privacy regulations at 12 C.F.R. Part 1070, et seq. We anticipate this application form taking about 10
minutes of your time.
Also please remember that completing this form is voluntary; you can choose not to answer any question, and you can
stop at any time.
Do you agree to complete the application survey?
[If Yes then continue]
Great, let’s get started. Please fill it out the application survey as accurately as possible, and feel free to ask me any
questions you have while completing it.

Appendix B
Financial Education Program Evaluation Support Services
Application Form

Name: _____________________
DOB: ___/___/_______
Social Security Number or Tax Identification Number: ____ - ____- _______
Address: ____________________________ Apt # _______
________________________________________________

Telephone Number: (_______) ________-________
Cell phone number: (_______) ________-________

Email address: ______________________________________________

Welcome to [insert organization name]! Please fill out the following survey.
1. Is this your first time at [Insert organization name] receiving services from this organization
□
□

Yes
No

2. How did you hear about the [Insert organization name]? [Note: For non-employer sites only]
□
□
□
□

Referral from ___________________________ (please write in)
Recommendation from family/friends
Saw an advertisement
Other. Please specify: _____________________________________

3. What is your main reason for considering receiving help from this program?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4. In the last 5 years, have you asked for any advice from a financial professional about any of the following? (Select an
answer for each)
Yes
A. Debt Counseling
B. Savings or Investments
C. Taking out a mortgage or a loan
D. Refinancing/renegotiating debt (including mortgage)
E. Insurance of any type
F. Tax planning

No

5. Please tell us about yourself by filling in the following table:

# of people in your
household (not
including you, write
in #’s)

Sex

o
o

Male
Female

# adults: _____
# children: _____

Hispanic
/ Latino

o
o

Yes
No

Race (check all that apply)

o
o
o
o
o

Black/African American
Caucasian/White
American Indian, Aleut,
Eskimo, Alaska Native
Asian
Native Hawaiian/ Pacific
Islander

Primary
Language
Spoken

Marital Status

o
o
o
o
o

Never
married
Married
Separated
Divorced
Widowed

o
o
o

English
Spanish
Haitian
Creole
o Mandarin
o Other:
Specify
__________

o
o
o
o
o
o
o
o
o
o

6. Were you born a US citizen?
□ Yes (If yes, SKIP to question 10)
□ No (If no, CONTINUE to question 7)
7. In what country were you born? _________________________________
8. Are you currently a naturalized citizen?
□ Yes
□ No
9. Are you a permanent resident of the United States?
□
□

Yes
No

Current Employment Status

Education Level (choose only one)

Self-employed
Work full-time for an employer
Work part-time for an
employer
Homemaker
Full-time student
Permanently sick, disabled,
unable to work
Unable to work due to
immigration status
Unemployed and actively
seeking employment
Unemployed, and not seeking
employment
Retired

o Less than HS Diploma
o High school diploma or
equivalent (GED)
o Some post-secondary
education
o Certification from a vocational
or technical training program
o Associate’s Degree
o Bachelor’s Degree
o Master’s or other graduate
degree
o Other Specify:

10. What are some of the goals you hope your financial coach can help you achieve? Please indicate whether or not any
of the following are goals you wish to achieve, and if so, how close you feel you are to achieving this goal.
I have
this goal

Goal

Yes

B

Increase non-retirement savings or
emergency /“rainy day” funds
Increase retirement savings

C

Increase savings for children’s education

D

Housing: home ownership/improvement
apartment rental

E

A big purchase, for example a car

F

Education/training

G

Starting/improving my own business

H

Improving credit

I

Paying down debts

J

Improving my money management
(budgeting) skills

K

Improving my household’s financial security/
be able to better take care of family/ live
more comfortably

A

No

How much progress have you made towards
this goal?
A lot of
progress

Some
progress

A little
progress

No
progress

Other goal. Please specify:
L

11. What is your household’s monthly income: _________________
12. Please indicate if the amount you specified in Question 11 is:
□
□

Before Taxes
After Taxes

13. The following grid lists various cash accounts individuals sometimes have. Please indicate whether or not you have
any of the following accounts by answering “yes” or “no”, and if “yes,” what your approximate current balance is.
Cash Accounts
A. Checking accounts
B. Savings accounts
C. Other cash accounts (e.g. money market accounts and savings
certificates). Please specify:

Yes

No

Estimated
Current Balance

14. Do you have paychecks directly deposited into one of these accounts?
□
□
□
□

Yes
No
Does not apply
Don’t know

15. How many active credit cards (not including prepaid or debit cards) do you currently have? Please write in the
number: ______
16. How often is your household able to pay its bills on time? Please choose the most appropriate statement. (Mark only
one)
□ Most of the time (late 1 time or less per year)
□ Very Often (late 2-3 times per year)
□ Sometimes (late every other month)
□ Rarely or never (late about every month)
17. Below is a list of financial alternatives to traditional banking services which are commonly used. Please indicate
whether or not you have used the following activities in the past 3 months by answering “yes” or “no” for each one. For
those you answer “yes,” please also indicate the number of times you have done so in the past three months.

Activity

Yes

No

A. I borrowed money from friends/family
B. I obtained cash from a payday loan in anticipation of an upcoming
paycheck.
C. I sold or pawned something to a pawn shop.
D. I obtained an auto title loan. (Auto title loans are loans where a car title is
used to borrow money for a short period of time. They are NOT loans used
to purchase an automobile.)
E. Credit card cash advance

18. Approximately how often do you put aside money for savings?
□ Twice a month
□ every 1-2 months
□ 1-2 times per year
□ Never
□ Don’t Know
19. Where do you typically put your savings? (Check all that apply)
□
□
□
□
□
□
□
□

I have no savings at this time
Savings account
Checking account
Savings bonds
Keep cash at home
Individual Development Account (IDA) or a matched savings account
Individual Retirement Account (IRA) or 401K Account
Someplace else. Please specify: ____________

# times
in past 3
months

20. Have you set aside emergency or rainy day funds that would cover your expenses in case of sickness, job loss,
economic downturn, or other emergencies?
□
□
□

Yes (Go to Question 21)
No (SKIP Question 21)
Don’t know

21. If How much money have you set aside in your emergency fund? Please write in amount: _____________

Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to
collect the names, telephone numbers, and addresses of three people who will know how to reach you. Please tell me
about people who live at different addresses. This information will be kept strictly confidential and will only be used if
we are unable to contact you.
CONTACT #1
Name:
Street Address:
Telephone Number: (_______) ________-________
Cell phone number: (_______) ________-________
Email address: ______________________________________________
Relationship to you: _____________________________________________

CONTACT #2
Name:
Street Address:
Telephone Number: (_______) ________-________
Cell phone number: (_______) ________-________
Email address: ______________________________________________
Relationship to you: _____________________________________________

CONTACT #3
Name:
Street Address:
Telephone Number: (_______) ________-________
Cell phone number: (_______) ________-________
Email address: ______________________________________________
Relationship to you: _____________________________________________