Taxpayer Survey
Please complete this optional survey to help us secure funding and stay open. Your answers will not impact your tax return. We will not report personally identifying information. Thank you for your help! (to be completed by the primary taxpayer)
Name
*
First Name
Middle Name
Last Name
*
I will answer
I prefer to opt out of all questions
1. How did you hear about the Free Tax Site?
a. Friend/Family member
b. Brochure, poster, or flyer
c. Newspaper, television, or radio
d. Social media (such as Facebook)
e. Community Action Duluth Website
f. Referred by IRS or MNDOR
g. Referred by other community agency
Other
2. What is the most important expense your tax refund will cover?
a. Housing expenses (rent, utilities, property tax)
b. Other basic needs (food, clothing, or transportation)
c. Tuition or other school expenses
d. Medical
e. Savings or investment
f. Enjoyment/fun
Other
3. What best describes your family's current housing arrangement?
a. Own
b. Rent
c. Lease
d. Other permanent housing
e. Houseless
f. I prefer not to answer
Other
4. What best describes your household type?
a. Single person
b. Two adults NO children
c. Single parent
d. Two parent household
e. Unrelated adults w/ children
f. Multi-generational household
Other
5. Including yourself, how many people live in your home?
6. How do you currently describe your gender identity?
If you prefer not to answer, leave blank
7. Do you or anyone in your household have a disability?
a. Yes
b. No
c. I prefer not to answer
8. Are you or your spouse a veteran from the U.S. Armed Forces?
a. Yes
b. No
c. I prefer not to answer
9. Which categories describe you? Select all that apply:
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Hispanic
g. I prefer not to answer
Some other race, ethnicity, or origin, please specify:
10. What is your highest level of education?
a. No high school
b. Some high school
c. High school diploma or equivalent
d. Vocational training
e. Some college
f. Associate's degree
g. Graduate or other post-secondary degree
11. How do you obtain health insurance?
a. Medicaid
b. Medicare
c. State Children's Health Insurance Program
d. State Health Insurance for Adults
e. Military Health Care
f. Direct purchase
g. Employment based
h. No health coverage
i. I prefer not to answer
12. What best describes your work status?
a. Employed full-time
b. Employed part-time
c. Migrant or seasonal farm worker
d. Short-term unemployed (6 months or less)
e. Long-term unemployed (more than 6 months)
f. Unemployed (not in the labor force)
g. Retired
Please select cash income sources that apply to your family:
a. Wages, salary or self-employment
b. TANF or MFIP
c. Supplemental Security Income (SSI)
d. Social Security Disability Income (SSDI)
e. VA Service-Connected Disability Comensation
f. VA Non-service Connected Disability Pension
g. Private disability insurance
h. Worker's compensation
i. Social Security retirement (SSA)
j. Pension
k. Child support
l. Alimony or spousal support
m. Unemployment insurance
n. Retirement savings
14. Non-cash income sources that apply to your family:
a. SNAP
b. WIC
c. LIHEAP
d. Housing choice voucher
e. Public Housing
f. Permanent Supportive
15. Housing that applies to your family:
a. HUD-VASH
b. Childcare voucher
c. Affordable Care Act Subsidy
Submit
Should be Empty: