Journey to Wealth Intake Form Journey to Wealth Intake Form "*" indicates required fields Name:* First Middle Last Date of Birth:* MM slash DD slash YYYY Email:* Co-Applicant Name: First Middle Last Co-Applicant Date of Birth: MM slash DD slash YYYY Co-Applicant Email: Current Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Phone Number:*Alternate Phone Number:Gender:* Male Female Other Are you disabled?* Yes No Are you a veteran?* Yes No Marital Status:* Single Married Divorced Separated Widowed Race:* African American/Black White Asian Somali Native Hawaiian/Pacific Islander American Indian/Alaska Native Other Ethnicity* Hispanic or Latino Not Hispanic or Latino Total Household Size:*Number of Dependents:*Age of Dependent(s): Education:* College Graduate School High School GED Junior High School Vocational None Other Rural Area Status:* Rural Non-Rural No Response Limited English Proficiency Status:* English Proficient Limited English Proficient No Response Landlord/Complex Name: Contact Person: Phone: Fax: Lease: Sec 8/Voucher: Monthly Rent: Applicant's Employer: Hire Date: MM slash DD slash YYYY Job Title: Gross Income (Annual): Net Monthly Income: Paid: Weekly Every Two Weeks Twice a Month Monthly Other Co-Applicant's Employer: Co-Applicant's Hire Date: MM slash DD slash YYYY Co-Applicant's Job Title: Co-Applicant's Gross Income (Annual): Co-Applicant's Net Monthly Income: Co-Applicant Paid: Weekly Every Two Weeks Twice a Month Monthly Other Additional Income Source (check one): Job & Family Services Social Security SS Disability Other Monthly Income from other sources: Credit Summary Info — Bankruptcy?* Yes No If yes, date: MM slash DD slash YYYY Judgement(s)?* Yes No If yes, date: MM slash DD slash YYYY Collections: Savings: Checking: Credit Score: Late Accounts: Derogatory Accounts: TANF (Temporary Assistance for Needy Families):* Yes No If yes, check all that apply: Food Stamps Medical Cash Child Care Title XX Would you like to request a copy of your Credit Report for review?* Yes No Is there any other information you believe we should know?By checking this box, I hereby give Permission for the designated representative of the Columbus Urban League’s Financial Empowerment Services Department to obtain information or copies of my financial, legal or other pertinent file, to facilitate my case, via said office.* Yes PhoneThis field is for validation purposes and should be left unchanged.
