Debt Consciousness Assessment Debt Consciousness AssessmentPlease enable JavaScript in your browser to complete this form.Name *FirstLastDISCLAIMER: Your information and data collected will be held in strict confidence. Your name will not be openly shared or connected with any of your responses, nor will we identify you with your responses to third parties without your consent. Please refer to https://prfinstitute.org/privacy-policy/ for further details.Email *EmailConfirm EmailZip Code *Are you an active member of a church or other religious organization?YesNoName of community, religious, non-profit, or business affiliation. *** SELECT FROM THE LIST BELOW ***Mount Moriah Baptist Church, Auburn, ALcond ChoiceOpelika First Assembly (Pioneer Network), Opelika, ALThe Edge, Inc., Auburn, ALFirst Baptist Church of Ensley, Birmingham, ALMt. Moriah Missionary Baptist Church, Hurtsboro, ALGreater Peace Baptist Church, Opelika, ALFirst Presbyterian Church, Opelika, ALHis Gathering House, Phenix City, ALGreater Friendship Missionary Baptist Church, Tuskegee, AL2 Cities Church, Columbus, GARiver Valley Church, Columbus, GAEdgefield Baptist Church, Fayetteville, GAThe Refreshing A Place of Worship, Fayetteville, GAGreater Bethel AME Church, Charlotte, NCThe C. L. King Group Incorporated, Jacksonville, NCBerean Baptist Church, Philadelphia, PAReid Chapel AME Church, Columbia, SCMost Worshipful Prince Hall Grand Lodge of South CarolinaEC Global, Houston, TXOtherNo affiliation / Not applicableOrganizations are listed in order by city and state.D1. Age Range *18 to 2425 to 3435 to 4445 to 5455 to 6465 to 7474+D2. Race/Ethnicity *Black/African-AmericanWhite/CaucasianHispanic/LatinoAsianNative AmericanPrefer not to answerOtherD3. Marital status (as of today) *Single (never married)MarriedDivorcedDivorced and Re-marriedWidowedSeparatedPrefer not to answerD4. Number of children (or dependents) *This is to help us measure how many persons within a family unit that we could potentially assist. Enter N/A if you prefer not to answer.D5. Employment status (primary) *EmployedUnemployedRetiredSelf-employedMilitaryStudentOtherPrefer not to answerD6. GenderMaleFemale#1: How would you describe your current level of debt? *Don't knowA little burdened by itManageableIn way over my headI have no debt at all#2: Are you aware of your current debt-to-income ratio? *YesNo#3: Are you aware of your balance-to-limit ratios for your credit accounts? *YesNo#4: Have you been at least 30 – 120 days delinquent on any debts within the last 12 months? *YesNo#5: Has any life situations (unemployment, laid off, medical, divorce, etc.) happened to you over the last 24 months that make it a challenge to pay your debts consistently? *YesNo#6: Within the past 24 months, I have ______________ *completely stopped paying a debt(s) that I owed.made partial payment(s) on a debt(s).paid all of my debts are required.#7: Do you currently have any unpaid/negative debts due to co-signing for another? *YesPossiblyNo#8: Have you recently (within the last 12 months) considering filing for bankruptcy? *YesYes - occasionallyNo#9: When was the last time you filed for a Chapter 7 or 13 bankruptcy? *Never1 – 2 yrs ago3 – 4 yrs ago5 – 7 yrs ago+7 yrs ago#10: Are you aware of people around you (family, close friends, church members, etc.) experiencing potential to significant debt crisis AND in need of positive intervention? *YesNo#11: Do you have any unaddressed/negative debt situation(s) that you would like to address? *YesNo#12: Which PRIMARY debt of yours would you work to eliminate if you had the chance? *Student loan(s)MortgageCredit Card(s)Auto loan(s)Title PawnPayday LoanChild SupportLoan(s) to family/friendsBankruptcyOther loan(s)N/A - I have no debtPlease select no more than three.CommentSubmit
