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No = 1 Yes = 0
Do you own the home you live in?
Do you have investments, retirement accounts, inheritance money?
Do have access to family money in times of need?
Do you travel recreationally?
Do you work part-time by choice?
Do you have a high degree of earning power due to level of education (or gender or racial privilege, class background, etc)
TOTAL PART A (Maximum 6 pts): ____________
No = 0 Yes = 1
In the last 6 months, did you or your family:
Cut the size of your meals or skip meals because there wasn’t enough money for food?
Eat a less nutritionally balanced diet because there wasn’t enough money?
Are you supporting children or have other dependents?
Are you a single parent?
Do you have significant debt?
Do you have medical expenses not covered by insurance?
Do you have tuition/education expenses?
Do you receive public assistance?
Do you have immigration-related expenses?
Are you a senior citizen?
Are you a veteran or active military member?
TOTAL PART B (Maximum 11 pts): _____________
This scale is intended to help you look at your financial resources and take a deeper look at different levels of financial privilege. Make an honest assessment. The chart below is only intended as a guide. We believe you will pay what you can afford.
Add the points of Part A and Part B and please refer to the matrix below.