Contact InformationName(Required) First Last Email(Required) Cell Phone #(Required)Home Phone #Work Phone #Address(Required) Street Address Apartment/Unit # (if applicable) City State Zip Code What Ward/Neighborhood do you live in?(Required) Ward 1: Assembly Square, Cobble Hill, East Somerville, Foss Park, Inner Belt, North Point, Mystic River Ward 2: Boynton Yards, Brickbottom, Duck Village, Union Square Ward 3: Central Hill, Prospect Hill, Spring Hill Ward 4: Gilman Square, Temple Square, Ten Hills, Winter Hill Ward 5: Ball Square, Magoun Square, Porter Square Ward 6: Davis Square, Powder House Square, Tufts, West Somerville Ward 7: Clarendon Hill, Hillside, Teele Square Don't know / unsure Birthdate(Required) MM slash DD slash YYYY Gender(Required) Female Male Trans Female Trans Male Gender Nonconforming Other Ethnicity(Required) Hispanic Not Hispanic Chose Not to Respond * We are required to ask this as an organization that receives federal fundingRace(Required) American Indian/Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than One Race Prefer not to respond (please select one)What country were you born in?United StatesAlbaniaAlgeriaArgentinaBangladeshBarbadosBrazilCambodiaCameroonCanadaCape VerdeChileChinaColombiaCosta RicaCubaDominican RepublicEcuadorEgyptEl SalvadorEritreaEthiopiaFranceGermanyGhanaGuatemalaGuineaHaitiHondurasIndiaIndonesiaIrelandItalyIvory CoastJamaicaLebanonLiberiaMexicoMoroccoNepalNicaraguaPakistanPanamaParaguayPeruPolandPortugalPuerto RicoSomaliaTogoUgandaUruguayVenezuelaVietnamOtherWhat is your primary language(Required)EnglishSpanishAhmaricAlbanianAmerican Sign Language (ASL)ArabicBanglaBengaliBosnianCape Verdean CreoleChineseDutchEweFrenchGermanHaitian CreoleHindiIndonesianItalianJapaneseKhmerLugandaMaay MaayMandingoNepaliPortuguesePunjabiRussianSomaliSwahiliTagalogTigryanaOtherUrduVietnameseWhat is your secondary language? (if applicable)EnglishSpanishAhmaricAlbanianAmerican Sign Language (ASL)ArabicBanglaBengaliBosnianCape Verdean CreoleChineseDutchEweFrenchGermanHaitian CreoleHindiIndonesianItalianJapaneseKhmerLugandaMaay MaayMandingoNepaliPortuguesePunjabiRussianSomaliSwahiliTagalogTigryanaUrduVietnameseOtherWhat is your English proficiency?(Required) Fluent Near native Advanced Intermediate Low-intermediate Beginner Family InformationNumber of adults in household(Required)Number onlyNumber of children in household(Required)Number onlyYour marital statusSingleMarriedLiving with PartnerSeparatedDivorcedWidowedIf separated/divorced and a custodial parent, are you receiving child support?YesNoHousingWhich of these options best describes your current housing situation?(Required)Shelter or transitional housingCurrently looking for housingPublic HousingSection 8 Mobile VoucherProject-Based Section 8Apartment paying market-rate rentLiving with family/friendsHomeownerShared HousingOtherIf Other Are you able to pay your rent/mortgage in full on time every month?YesNoAre you late on your rent/mortgage?YesNoHow much do you owe?EducationHighest level of education completed(Required) Some high school or less High school diploma GED Some College Vocational Degree Associate's Degree Bachelor's degree Graduate Degree Country of highest level of education United States Not in the United States Employment InformationWhat is your current employment status?(Required)Employed more than full-timeEmployed full-timeSelf-EmployedEmployed part-timeCurrently looking for workWorking at homeWorking and in school/trainingHomemakerLaid off, waiting for call-backDisabledCurrently in school/trainingRetiredIncomeWhat is your monthly household income?(Required)Required for reporting purposes (numbers only)What are your current source(s) of income?(Required) Employment TAFDC/EAEDC Unemployment Food Stamps SSI/SSDI Child Support Rental Income Other Other source of income Have you received EITC/CTC/Child and Dependent Care Credit? Yes No I don't know Financial GoalsWhich of the below topics do you think you need more information on? Budgeting Credit Insurance Savings Investing Retirement Homebuying Other (list below) Other Topics Please list any Financial Goals here:SCC InformationHow did you hear about Somerville Community Corporation? Agency Referral CHW Grant Program Community Event Email Employer Flyer Former First Source Participant SCALE SCC SCC Tenant SomerNova SomerViva Somerville High School Website/Social Media Other If other Agency Name(Required) Which website or social media platform?
