Forward Memphis | Financial Coaching Assessment

MONTHLY INCOME

Please let us know below all of your monthly income. If you do not have a cost associated with one of the expenses listed below, please place a zero.
What is your total gross monthly household income?*
Gross Income is the income you receive BEFORE taxes are taken out. Include all sources of income.
ADDITIONAL INCOME
Do you receive any other monthly income?*

YesNo
Please list how much additional income you receive and the source of income. *
If none, place a "0"
Have you filed your income taxes for this year?*

YesNo
Did you receive a tax refund this year or are you anticipating receiving a refund this year?*

YesNo

HOUSING

Please let us know below all of your monthly expenses related to housing. If you do not have a cost associated with one of the expenses listed below, please place a zero.
What is your Monthly Mortgage or Rent Amount?*
Does your mortgage payment include taxes and insurance?*

YesNoN/A, I am a Renter
Total Cost of Your Monthly Utility Bill*
Please only include the cost for electricity, gas, and water. Do not include Wi-Fi, cable, or other costs.
Monthly Cable Cost*
Please do not include streaming services like Netflix, Hulu, Disney + Amazon Prime, etc.
Monthly Internet Cost*
Wi-Fi services
Monthly Phone Bill*
This should include mobile phone as well as landline costs.
Other Misc. Housing Expenses*
This may include monthly amounts for trash pick-up, an alarm system, lawn maintenance, pest control, or other recurring household expenses.
Are you past due on any of your housing bills?*

YesNo
List any past due housing bills including the exact amount.*
If you are current on all bills please place a "N/A".
Monthly Grocery Cost*
Please include any and all spending at the grocery store (i.e. food, toiletries, laundry detergent, etc.)
Do you receive food stamps?*

YesNo
How much do you receive?*

AUTOMOBILE

Please let us know below all of your monthly expenses related to automobile/transportation. If you do not have a cost associated with one of the expenses listed below, please place a zero.
Total Monthly Car Note(s)*
If none, please place "0".
Total Monthly Gas & Oil Cost*
Total Monthly Car Insurance Cost*
Are you past due on your car note or car insurance?*

YesNo
List any past due bill for your auto including the exact amount.*
If you are current on all bills please place a "N/A".

HEALTH INSURANCE

Please let us know all your monthly health insurance expenses. If you do not have a cost associated with one of the expenses listed below, please place a zero.
Monthly Medical & Life Insurance Cost*
List any Medical, Disability or Life Insurance benefits you pay each month which ARE NOT provided by your employer. DO NOT LIST any benefits automatically deducted from your paycheck.
Do you have any other insurance that is not deducted from your paycheck?*

YesNo

OUTSTANDING DEBTS

Please use the table below to tell us more about your current debts. This would include credit card debt, car loans, student loans, title or payday loans, medical debt, mortgage, etc. Even if you may have already submitted this information earlier in this form, please include it here.
Do you currently have a title or payday loan?*

YesNo
If you have a title loan, how much do you owe?*
If none, please place "0".

Input Debts Here:

	DESCRIPTION OF DEBT	MINIMUM MONTHLY PAYMENT	TOTAL BALANCE	MY PAYMENTS ARE...	INTEREST RATE
DEBT 1
DEBT 2
DEBT 3
DEBT 4
DEBT 5
DEBT 6
DEBT 7
DEBT 8
DEBT 9
DEBT 10

PERSONAL SAVINGS/INVESTMENTS

Please let us know below all of your monthly expenses related to savings and investments. If you do not have a cost associated with one of the expenses listed below, please place a zero.
How much do you currently have in your savings?*
If none, place "0".
How much do you have in other investments including your retirement savings?*
I.e., 401(k), IRA's, 403(b), or any additional personal investments.

ADDITIONAL EXPENSES

Please let us know below all of your miscellaneous monthly expenses. If you do not have a cost associated with one of the expenses listed below, please place a zero.
Monthly Prescriptions and/or Over The Counter Medicine*
Other*
Anything else that may not fall in the above categories.
School/Childcare Expenses
Monthly Education Costs*
I.e. School supplies, school activities, etc.
Monthly Daycare/ Aftercare costs*
I.e. Private school, day care, higher education, etc.
Miscellaneous Expenses
Additional Expenses not already covered.*
I.e. Private school, day care, higher education, etc.

ADDITIONAL INFORMATION
Do you have written documentation that shows your emergency need and out of pocket expense?*

YesNo
Is there anything else you'd like to make us aware of regarding your request?
As part of our prequalification process, we must receive documentation reflecting one month of current income. (biweekly/semi-monthly pay frequency = 2 pay stubs and weekly pay frequency = 4 pay stubs)*

File types accepted: PDF is the preferred file type.
Cancelof
As part of our process, we must receive your most recent 30 day bank statement. *

File types accepted: PDF is the preferred file type.
Cancelof
If you are seeking emergency financial assistance, we must receive supporting documentation of your need. You may upload your document(s) here or email them to: coaching@forwardmemphis.com.

File types accepted: PDF is the preferred file type.
Cancelof
If you would like to email your documentation, you may send it to
coaching@forwardmemphis.com and include your first and last name in the subject line.
I understand that my application will remain on hold until the required documentation is received by Forward Memphis.*

Yes

FINANCIAL COACHING DISCLAIMER & WAIVER
1. Forward Memphis is providing financial coaching services (referred herein as the (“Services”) to him and/or her solely on an advisory basis. The Services are being provided with the understanding that Forward Memphis is not engaged in rendering legal, tax, financial, counseling, or other professional services or advice.

2. Participant(s) use of the Services indicates Participant(s)’ understanding that the Participant(s)’ is/are able to make his or her own decisions about financial matters, and Forward Memphis is not responsible for any financial decisions or funding decisions made by Participant(s)’, or which Participant(s)’ fail to make.

3. Forward Memphis’ Services are being provided free of charge to you.

4. In general, all communication between Participant(s)’ and Forward Memphis are confidential. No information about Participant(s) will be released outside of Forward Memphis without Participant(s)’ permission. The EXCEPTIONS to confidentiality include, but are not limited to, the following: Forward Memphis determines Participant(s) is a threat to himself or herself, or another person; (2) there is suspected abuse or neglect of a child, an elderly or disabled person; (3) Participant(s) is threatening to commit a crime; (4) there is a medical emergency; or (5) through a court order to disclose Participant(s)’ records. In the event of such a situation, Forward Memphis will make reasonable efforts to discuss it with Participant(s) before taking any action.

5. Participant(s) hereby waives any and all claims against Forward Memphis, its directors, officers, employees, volunteers, agents, and other members that relate to financial coaching services or the consequences that may occur as a result of following the advice given. Any disputes that may arise between Participant(s) and Forward Memphis shall be resolved by mediation.

Indicate your agreement to the above Disclaimer and Waiver by filling in your name below. By typing your name below, you are signing this document electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Yes, I acknowledge that financial coaching is a requirement of the Freedom Fund program and any financial assistance that may be offered is based on the coaching recommendations of Forward Memphis.*

Yes
Yes, I acknowledge that I must complete the coaching recommendations of Forward Memphis before any funds are dispersed on my behalf.*

Yes
Yes, I understand that any funds provided through the Freedom Fund program are payable directly to a third party on my behalf.*

Yes
Yes, I acknowledge that Forward Memphis, its employees and/or volunteers will not be held liable for the financial coaching received.*

Yes
Type Your Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
**The Financial Coaching of Forward Memphis is intended to provide basic financial knowledge. We are not licensed to provide tax, legal, or investment advice. If any information of this nature is given during a coaching session, it is solely the view of the individual and is not endorsed nor advised by Forward Memphis. Please acknowledge that you understand that information of this nature should not be provided through this organization and that you release Forward Memphis and its volunteers from any liability regarding the outcomes.
Should be Empty:

FREEDOM FUND PREQUALIFICATION FORM

PERSONAL INFORMATION

MONTHLY INCOME

ADDITIONAL INCOME

HOUSING

AUTOMOBILE

HEALTH INSURANCE

OUTSTANDING DEBTS

PERSONAL SAVINGS/INVESTMENTS

ADDITIONAL EXPENSES

School/Childcare Expenses

Miscellaneous Expenses

ADDITIONAL INFORMATION

FINANCIAL COACHING DISCLAIMER & WAIVER