Updated - Free to Save Program Application and Eligibility Form

Free to Save Program Application and Eligibility Form
First Name (Adult 1)
For Excel Sheet
Middle Name (Adult 1)
For Excel Sheet
Last Name (Adult 1)
For Excel Sheet
Financial Literacy Class Taken - Adult 1
Date FLC Completed - Adult 1
Contacted
For Calculation in Excel Sheet
Overall Eligible
For Calculation in Excel Sheet
Asset Savings and Purchase Eligible
For Calculation in Excel Sheet
Income Eligible
For Calculation in Excel Sheet
Net Worth Eligible
For Calculation in Excel Sheet
Location Eligible
For Calculation in Excel Sheet
The Free to Save Program offers three services: Financial Literacy Classes, 1:1 Coaching and Asset Savings & Purchase. You must be at least 18 years old and be a resident living in Lancaster or Saunders Counties Nebraska to be eligible for this program. Eligible participants must also meet income (200% of poverty guidelines) and net worth (less than $10,000) requirements. The Free to Save Matched Savings Program is not intended to address immediate needs.

Financial Literacy Classes are six weeks of classes that meet once per week, for two hours. Once completed you are eligible to continue with six months of 1:1 Coaching.

The Asset Savings & Purchase portion of this program provides a 4:1 savings match for the following assets: first time home, vehicle, post-secondary education and small business start-up or expansion. Individuals are only eligible to participate in the Asset Saving & Purchase portion one time. The waitlist for the Asset Saving & Purchase portion is fluid, based on applications received.

Applications expire after six months. To stay on the waitlist, you must reapply.
I understand and wish to proceedI am not interested at this time

Total Number in Household
Income - 200% Poverty Level
For Calculation on Excel Sheet
Total Household Income
Program Eligible Assets
Does not include home value and vehicle 1 (most valuable)
Program Eligible Liabilities
Does not include mortgage loan and vehicle 1 loan (most valuable)
Program Eligible Net Worth
Does not include home value, mortgage loan, vehicle 1 (most valuable), and vehicle 1 loan (most valuable)
Waitlist Score
Asset Type
First Adult's Information

Head of Household
First Name*
Middle Name*
Last Name*
Birth Date*

MonthDayYear
Date
Phone Number*
Street Address*
Example: 111 Happy Dr. Apt # 2
City*
State*
Zip Code*
Example: 68508
County of Residence*

LancasterSaundersOther
Email*

Confirmation Emailexample@example.com
Definition of Household:

A household is all individuals who reside in a dwelling unit who live and eat separately from other individuals in that unit. There may be subgroups within the same dwelling unit. One subgroup combines income and resources and eats together. Even though they pay a portion of the rent, they do not combine income or resources with the other subgroup(s) that are also paying a portion of the rent. Each subgroup is a separate household.
Total Number of People in Household*
Number of Adults (18+) in the Household*
Number of Children (0-17) in the Household*
How did you hear about the program?*
Are you applying with anyone else in your household?*

YesNo
What is the name of the second adult?*
What languages are spoken in the household?*
This program is facilitated in English, given this, would you like an interpreter?*

YesNo
What language would you like interpretation in?*
First Adult's Income

Enter the monthly amounts for each type of income you receive.
First Adult's Total Monthly Income*
Monthly Gross Wages from Employer*
Wages before taxes are taken out. Do not include any amounts from self-employment.
Self-Employment (If you own your business)*
Monthly
TANF/ADC*
Monthly
General Assistance*
Monthly
SSI - Monthly Income Received*
Monthly
Social Security Disability - Monthly income Received*
Monthly
Social Security Retirement - Monthly Income Received*
Monthly
Child Support*
Monthly
Alimony/Spousal Support*
Monthly
VA Service-Connected Disability*
Monthly
VA Non-Service Disability*
Monthly
Pension or Retirement*
Monthly
Other Income*
Monthly
What is your "Other" Income?*
Second Adult's Information
Second Adult First Name*
Second Adult Middle Name*
Second Adult Last Name*
Financial Literacy Class Taken (Adult 2)
Date FLC Completed (Adult 2)
Birth Date*

MonthDayYear
Date
Phone Number*
Email*

Confirmation Emailexample@example.com
Second Adult's Income

Enter the monthly amounts for each type of income you receive.
Second Adult's Total Monthly Income*
Monthly Gross Wages from Employer*
Wages before taxes are taken out. Do not include any amounts from self-employment.
Self-Employment (If you own your business)*
Monthly
TANF/ADC*
Monthly
General Assistance*
Monthly
SSI - Monthly Income Received*
Monthly
Social Security Disability - Monthly Income Received*
Monthly
Social Security Retirement - Monthly Income Received*
Monthly
Child Support*
Monthly
Alimony/Spousal Support*
Monthly
VA Service-Connected Disability*
Monthly
VA Non-Service Disability*
Monthly
Pension or Retirement*
Monthly
Other Income*
Monthly
What is your "Other" Income?*
Third Adult's Information
Third Adult First Name*
Third Adult Middle Name*
Third Adult Last Name*
Birth Date*

MonthDayYear
Date
Phone Number*
Email*

Confirmation Emailexample@example.com
Third Adult's Income

Enter the monthly amounts for each type of income you receive.
Third Adult's Total Monthly Income*
Monthly Gross Wages from Employer*
Wages before taxes are taken out. Do not include any amounts from self-employment.
Self-Employment (If you own your business)*
Monthly
TANF/ADC*
Monthly
General Assistance*
Monthly
SSI - Monthly Income Received*
Monthly
Social Security Disability - Monthly Income Received*
Monthly
Social Security Retirement - Monthly Income Received*
Monthly
Child Support*
Monthly
Alimony/Spousal Support*
Monthly
VA Service-Connected Disability*
Monthly
VA Non-Service Disability*
Monthly
Pension or Retirement*
Monthly
Other Income*
Monthly
What is your "Other" Income?*
Fourth Adult's Information
Forth Adult First Name*
Forth Adult Middle Name*
Forth Adult Last Name*
Birth Date*

MonthDayYear
Date
Phone Number*
Email*

Confirmation Emailexample@example.com
Fourth Adult's Income

Enter the monthly amounts for each type of income you receive.
Fourth Adult's Total Monthly Income*
Monthly Gross Wages from Employer*
Wages before taxes are taken out. Do not include any amounts from self-employment.
Self-Employment (If you own your business)*
Monthly
TANF/ADC*
Monthly
General Assistance*
Monthly
SSI - Monthly Income Received *
Monthly
Social Security Disability - Monthly Income Received *
Monthly
Social Security Retirement - Monthly Income Received*
Monthly
Child Support*
Monthly
Alimony/Spousal Support*
Monthly
VA Service-Connected Disability*
Monthly
VA Non-Service Disability*
Monthly
Pension or Retirement*
Monthly
Other Income*
Monthly
What is your "Other" Income?*
Household Assets

List the estimated value of what every adult (18+) living in the household owns.
Do you own the house you live in?*

YesNo
Value of House*
Total market value of your house. For estimated value of home in Lancaster county - https://orion.lancaster.ne.gov/. For estimated value of house in Saunders county - https://saunders.nebraskaassessors.com/
How many vehicles does your household own?*

ZeroOneTwoThree or more
Vehicle 1 - (Vehicle worth the most money)
Vehicle 1 - Year/Make/Model - (Vehicle worth the most money)*
Vehicle 1 - Current Mileage*
Vehicle 1 - Current Value - (Vehicle worth the most money)*
Total market value of your vehicle. You can get an estimate at www.kbb.com
Vehicle 2
Vehicle 2 - Year/Make/Model*
Vehicle 2 - Current Mileage*
Vehicle 2 - Current Value*
Total market value of your vehicle. You can get an estimate at www.kbb.com
Vehicle 3
Vehicle 3 - Year/Make/Model*
Vehicle 3 - Current Mileage*
Vehicle 3 - Current Value*
Total market value of your vehicle. You can get an estimate at www.kbb.com
Total Household Savings Accounts Balances*
Include all the following: Bank accounts, Credit Unions, and Online Banks
Total Household Checking Accounts Balances*
Include all the following: Bank accounts, Credit Unions, and Online Banks
Total Household Cash Apps Balances*
Include all the following: Cash Apps (Venmo, PayPal, CashApp, etc)
Total Household Retirement Accounts*
Examples: 401K, IRA, Roth, etc
Total Household Investment Accounts*
Examples: Certificates of Deposit (CDs), Money Market account, Stocks, Real Estate, Bonds, Mutual Funds etc
Household Liabilities

List the amounts every adult (18+) living in the household owes to others.
Mortgage/Home Equity Loan*
Total amount that is currently owed.
Vehicle 1 Loans - (Vehicle worth the most money)*
Total amount that is currently owed
Vehicle 2 Loans*
Total amount that is currently owed
Vehicle 3 Loans*
Total amount that is currently owed
All Student Loans*
Other Loans*
Credit Card Balances*
Medical Debts*
Collections Debts*
Other Debt*
What is your other debt?*
Total Household Assets
For spreadsheet calculation only.
Total Household Liabilities
For spreadsheet calculation only.
Total Household Net Worth
For spreadsheet calculation only.
Program and Desired Asset Questions
1. Do you currently participate in any Community Action programs?*

YesNo
What Community Action programs are you currently in or receive services from? (Select all that apply)*

Early Head Start CenterEarly Head Start Home-basedHead StartFoster Grandparent ProgramEmergency Services (rent, utility, and deposit assistance)Supportive HousingTenant Support ServiceAffordable HousingDisplaced Tenant AssistanceYouth Homelessness Demonstration ProgramFinancial CoachingWeatherizationGathering PlaceHealthy Food Access Program (FEAST)
2. Have you completed Community Action's Financial Coaching Classes?*

YesNo
When did you complete Community Action's Financial Coaching Classes?*
Month, Year
3. Do you have a weekly/monthly budget plan that you follow?*

No budget planHas budget plan, but does not followHas budget plan, follows 10-50% of the timeHas budget plan, follows 60-80% of the timeHas budget plan, follows 90-100% of the time
4. Do you regularly save money each month?*

No, not do currently save moneySometimes, when possibleYes, save every month
5. This program requires you to make regular savings contributions of at least $50 per month/per applicant. Would your current income allow you to complete this requirement?*

YesNo
6. This program requires you to open an IDA (Individual Development Account) savings account with US Bank. Are you able to open a new bank account?*

YesNo
7. This program offers assistance with credit building and repair. Select the best description of your credit history and debt.*

I have significant negative credit history and/or significant debtI have moderate negative credit history and/or moderate debtI have positive credit history and/or few/manageable debts
8. Have you experienced discrimination that has negatively impacted your ability to purchase an asset?*

YesNo
9. What type of asset would you like to purchase through the program?*

VehicleHomePost-Secondary EducationSmall Business Start-Up or Expansion
10. Do you currently have a valid driver's license?*

YesNo
11. How many miles are currently on the vehicle you are wishing to replace?*

0-129,000 miles130,000-145,000 miles145,000-160,000 miles160,000-175,000 miles175,000-200,000 milesOver 200,000 miles or no vehicle
12. What timeline are you considering for the purchase of a vehicle?*

6-8 months9-12 months13-18 months19-24 months25 months or more
13. How would you use this vehicle for transportation? (Select all that apply)*

SociallyHousehold errandsTaking children to child careGoing to school/taking children to schoolGoing to a job
10. Do you feel safe in your current living conditions?*

YesNo
11. How long have you had consistent income?*

No income0-11 months1-2 years3-4 years5 years or more
12. What timeline are you considering for the purchase of a home?*

6-8 months9-12 months13-18 months18-24 months24 months or more
13. Do you qualify as a first time home owner?*

YesNo
10. Do you have a plan to use the degree/certificate once completed?

No planGeneral planCareer goalsSpecific career pathSpecific job is waiting
11. Have you completed the required prerequisites? (GED, High School diploma, entry level certificates, etc.)*

YesNo
12. Have you been accepted or enrolled in an education/certificate program?*

Not applied yetApplied not yet acceptedAccepted not yet enrolledCurrently enrolledCurrently enrolled with some completed credits
13. Are you the first in your family to seek higher education/work certificate?*

YesNo
10. Do you have a plan to use the funds for a small business start-up or expansion?*

No ideaVague ideaClear ideaClear idea, partially written planClear idea, completed written plan
11. Do you have a business mentor or business community you can go to for support?*

YesNo
12. How much experience do you have in your desired business field?*

No experience0-11 months1-2 years3-4 years5 or more years
13. Would your business qualify as a minority owned business?*

YesNo

Certification of Accuracy

By signing below, I hereby certify that all information provided on this application is accurate and complete to the best of my knowledge.
Date Filled Out*

MonthDayYear
Date
First Adult's Signature*

Clear
First Adult's Current Age*
Second Adult's Signature*

Clear
Second Adult's Current Age*
Third Adult's Signature*

Clear
Third Adult's Current Age*
Fourth Adult's Signature*

Clear
Fourth Adult's Current Age*
Should be Empty:

Free to Save Program Application and Eligibility Form

First Adult's Information

First Adult's Income

Second Adult's Information

Second Adult's Income

Third Adult's Information

Third Adult's Income

Fourth Adult's Information

Fourth Adult's Income

Household Assets

Vehicle 1 - (Vehicle worth the most money)

Vehicle 2

Vehicle 3

Household Liabilities

Program and Desired Asset Questions

Certification of Accuracy