Annual Survey

Survey Response Form

Friends of the North Country, Inc.
Full Name:*

First NameLast Name
Do you have a co-applicant?

YesNo
Co-applicant's name:*

First NameLast Name
Property Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Is mailing address different from property address?*

YesNo
Mailing Address: (if different)*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Alternate Number:
Please enter a valid phone number.
E-mail:
example@example.com
Preferred method of contact:*

PhoneAlternate PhoneEmailMailOther
Housing Information

Please explain your living situaion.
Where do you currently live?*

Own homeRent in traditional housingRent in subsidized housingWith friends or family, not paying rentWith friends or family, paying rentTransitional Shelter/Homeless
Please explain your type of ownership:*

Deeded OwnerLife LeaseLand contractOther
How long have you been living there?*
What town are the land taxes paid to?*
Are the property's land and school taxes paid and up-to-date?*

YesNo
Would you like us to contact you about help with your late taxes?

YesNo
What year was the home built? (estimates are acceptable)
Is the home manufactured or modular housing?*

YesNoUnsure
Do you have a mortgage?*

YesNo
Are you up to date on mortgage payments?

YesNoYes, but I'm worried I'll fall behind soon
Would you like us to contact you about help with your mortgage?

YesNo
Who is it with?
Please list the name of your lender and/or loan servicer.
Are you behind on your rent?*

NoYesNo, but I am worried I am going to fall behind
How long have you been homeless or at risk of homelessness?
Please select any organizations you are currently receiving help from*

LASNNY/Rural LawClinton County HousingJCEOUnited WayCommunity Housing CouncilCatholic CharitiesETC HousingSocial ServicesNoneOther
What caused your affordable housing problems?*
Household Information

Please include yourself and anyone else living in the home.
Number of total household members:*
How many household members under 18?*
How many household members over 62?*
How many household members are disabled?*

Household Income (for ALL MEMBERS of the household over the age of 18):*

	HH Member Name:	Income Gross:	Income Net:	Source:	Frequency:
1
2
3
4

Needs

Please select what types of assistance you are looking for.
Do you have any home repair or replacement needs?*

YesNo
Housing Barriers: which of the following need to be repaired/replaced? (Check all that apply)*

Roof/chimneyElectricalPlumbingHeatingInsulation/weatherizationFoundationExterior/sidingDoors/windowsSeptic/wellOther
Do you or anyone in your home have disabilities that make living at home difficult?*

YesNo
Housing Barriers: what adaptations would allow you or your family member to comfortably and safely remain in the home? (Check all that apply)*

RampExpanded doorwaysHand-held showerGrab barsHandrailsNon-skid flooringRoll-in showerStair glidesEasy-to-reach work & storageStrobe light/vibrating smoke alarmOther
Please select any services you have an interest in:*

Pre-purchase/Homebuyer CounselingPost-purchase CounselingCredit & Budget CounselingForeclosure InterventionTenancy (Rental) CounselingHECM (Reverse) Mortgage CounselingHomeless AssistanceNoneHome Repair GrantsOther
Budget

If you are interested in having a counselor help you with any of the above affordable housing needs, please complete the budget below. For annual expenses, divide by 12 to get the monthly amount. If you need help, leave it blank and a counselor will call you to discuss.
I am in need of housing services and I understand that in order to receive them I must submit an updated budget.*

Yes, I will complete the budget form.No thank you, I am not interested at this time.I need help, and would like a Housing Counselor to review with me over the phone.

Were you able to pursue the referrals given to you at intake?*

YesNoI don't remember/need new referrals
Would you like a staff member to contact you upon receipt of this form?*

YesNo
If you have any other comments, please leave them below.
Time

Hour Minutes

AM/PM Option
Please verify that you are human*
Should be Empty:

	Estimated Monthly Expense
Auto Insurance
Auto Loan
Tags/Registration
Repairs/Maintenance
Gasoline

	Estimated Monthly Expense
Mortgage
Homeowners Insurance
Property & School Taxes
Lawn care & snow removal
Rent

	Estimated Monthly Expense
Credit Card Payments
Credit Collections
Bankruptcy
Misc. Loans
Student Loans

	Estimated Monthly Expense
Health Insurance
Copays
Medications
Dentist
Other Insurance(s)

	Estimated Monthly Expense
Electricity
Water/Sewer
Trash Removal
Heating
Telephone(s)
Internet

	Estimated Monthly Expense
Dining Out
Books/Movies
Streaming (ex/ Netflix)
Cable TV
Gambling

	Estimated Monthly Expense
Child Care
Cleaning Supplies
Clothing
Personal Items/Toiletries
Laundry
Home Maintenance
Pet Supplies

	Estimated Monthly Expense
School Fees
Barber/Beauty Shop
Family Photos
Alcoholic Beverages
Tobacco
Vacations

	Estimated Monthly Expense
Birthday Gifts
Holiday Gifts
Charity

	Estimated Monthly Expense
Food at Work
Groceries
Meal Delivery

Survey Response Form

Housing Information

Household Information

Needs

Budget