Survey - HAP Test - Homes For Our Troops

*1.

Question - Required - Branch of Service
Please make between 1 and 3 selections from the choices below.

	Army
	Marines
	Navy
	Air Force
	Coast Guard

*2.

Question - Required - Stocks/Bonds/CD/Banks: Please list total value of all stocks, bonds,CD's, retirement & bank accounts currently held by you and/or spouse. (bank/company name, Account type: 401K, IRA, TSP, etc & balance)

*3.

Question - Required - Did you or your spouse receive a military bonus or severance pay during the last three years? If Yes, list amount & date paid.

Monthly Financial Responsibilities

*4.

Question - Required - Monthly Rent/Mortgage payment:

*5.

Question - Required - Monthly car payment(s):

*6.

Question - Required - Monthly electric payment:

*7.

Question - Required - Monthly gas/oil payment:

*8.

Question - Required - Monthly phone, cable, & internet payments:

*9.

Question - Required - Monthly cell phone payment:

*10.

Question - Required - Monthly grocery/food expenses:

*11.

Question - Required - Monthly clothing expenses:

*12.

Question - Required - Monthly court-ordered Child Support payments:

*13.

Question - Required - Monthly Health Insurance payment:

*14.

Question - Required - Monthly Life Insurance payment:

*15.

Question - Required - Monthly property insurance payment:

*16.

Question - Required - Monthly Auto Insurance payment:

*17.

Question - Required - Monthly Educational expenses:

*18.

Question - Required - Monthly child care payments:

*19.

Question - Required - Monthly credit card payment(s):

*20.

Question - Required - Other monthly payments (list type & amount):

Background Information

*21.

Question - Required - Have you or your spouse had any property foreclosed the last 7 years?

*22.

Question - Required - Have you or your spouse declared bankruptcy in the last 7 years?

*23.

Question - Required - Did you or your spouse have any debt due to a court decision against you? If yes, please explain.

*24.

Question - Required - Have you or your spouse ever been arrested or charged with a crime?

*25.

Question - Required - Have you or your spouse ever been convicted of a crime or a military court martial?

*26.

Question - Required - Are you or your spouse currently involved in a lawsuit?

*27.

Question - Required - Are you currently involved in a divorce proceeding?

*28.

Question - Required - Are there documented cases of involvement in spousal or child abuse for you or your spouse?

*29.

Question - Required - Are you or your spouse registered, or is either one of you required to register, as a sex offender?

*30.

Question - Required - Do you or your spouse currently receive alimony or child support? What is the monthly amount?

*31.

Question - Required - Are you presently working with and/or have you benefitted from ANY non-profit organization or community fundraiser since your injury? If yes, please list the organization's name, benefit received (include: financial assistance, vehicle donation, home modifications etc.) and value of donation.