Financial Coaching Program Application Form
The Financial Coaching Program serves individuals (18 years or older) with annual income at or below 200% of the federal poverty guidelines (currently, $30,120 for a one person household and $62,400 for a four person household) and a net worth of less than $10,000. You must live in Lancaster or Saunders counties.
First Name
*
Middle Name
*
Last Name
*
Preferred Name (if different from given name)
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Street Address
*
Example: 111 Happy Dr. Apt # 2
City
*
State
*
Zip Code
*
Example: 68508
Are you applying with anyone else in your household?
*
What languages are spoken in the household?
*
Our programming is in English. Given this, would you like an interpreter?
*
Yes
No
What language would you like an interpreter for?
*
Arabic
Spanish
Vietnamese
Karen
Russian
Ukrainian
Other
Other language
*
Participant's Signature
*
Signed Date
*
-
Month
-
Day
Year
Date
Submit
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