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LOJ Community Center Intake Form
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The Love of Jesus Community Center of North Newark
Date of Intake
*
MM
/
DD
/
YYYY
First Name
*
Your answer
M.I.
Your answer
Last Name
*
Your answer
Spouse's First Name
Your answer
M.I.
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Spouse's Date of Birth
*
MM
/
DD
/
YYYY
Spouse's Age
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Primary Telephone Number
Your answer
Secondary Telephone Number
Your answer
Email Address
Your answer
Gender:
Male
Female
Other:
Clear selection
Marital Status
Married
Divorced
Single (Never Married)
Seperated
Widow(er)
Domestic Partner
Other:
Clear selection
Number of Children (Under 17) in Household:
Your answer
Number of Adults (18+) in Household:
Your answer
Number of dependents claimed on tax return:
Your answer
Status of Employment
*
Full-Time
Part-Time
Per-Diem
Retired
Disabled, not able to work
Unemployed
Other:
Household Income
*
Less than $10,000
$10,000-$14,999
$15,000-$24,999
$25,000-$34,999
$35,000-$49,999
$50,000 or more
Other:
What is your Highest Level of Education?
*
Some High School or Less
High School Diploma/GED
Vocational School
Some College
Bachelors
Masters
PhD
Other:
Are you receiving any of the following benefits?
TANF
GA
SSI/SDI
Unemployment
SNAP (Food Stamps)
Medicaid/Medicare
NONE
What type of Insurance do you have?
Medicaid
Medicare
Private
Marketplace
More than one type of Insurance
Uninsured
Other:
How would you identify your race/ethnicity (check all that apply)?
White
Black
Latino (any race)
Asian or Pacific Islander
Native American
Other:
How would you identify your spouse’s race/ethnicity (check all that apply)?
White
Black
Latino (any race)
Asian or Pacific Islander
Native American
Other:
Are you interested in other programs:
Financial Coaching/Credit Coaching
Incentivized Savings Program
Health Insurance
Early Childhood Programs
Housing Discrimination
Employment Services
Homeownership Counseling
Rental Assistance
Financial Aid (FAFSA)
Utility Assistance (PSE&G, etc.)
Feminine Hygiene Products
Children’s Diapers
Other:
What service are you here for today?
Financial Coaching/Credit Coaching
Financial Literacy Workshops
Youth Outreach Program
Food Pantry
First Time Homebuyer Workshop
Female Hygiene Products
Employment Services
Senior Chair Aerobics
Zumba Class
Children's Diapers
Business Development Workshop
Health Workshop
Other:
Are you a veteran?
Yes
No
Clear selection
Are you a home owner?
Yes
No
Clear selection
If yes, do you heat your home with oil?
Yes
No
Clear selection
Who prepared your (last year) tax return?
Family/Friend/Self
Free Tax Site
Paid Preparer
Didn’t File
Clear selection
If paid preparer how much did you pay to file your taxes? $ ___________
Your answer
How did you hear about this program?
Program Flyer/Brochure
Family/Friend
Mailing (postcard)
Social Media
NJ 211
Community Group
Organization
Other:
Name of the referring organization (if applicable)
Your answer
What type of bank account(s) do you have?
Checking Only
Savings Only
Checking & Savings
Pre-paid Card
I don’t have any accounts, but would like one
Check Systems Issue
Other:
How often do you worry about having enough money to cover your basic expenses?
Never
Not Very Often
Sometimes
Very Often
All the Time
Other:
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