Name

Contact Information Contact Information I wish to share my story, but remain anonymous You may provide my first name only You may provide my name and contact information if someone wishes to contact me for more information

What circumstances led you to seek services through your local Community Action Agency? What circumstances led you to seek services through your local Community Action Agency? Rent/Utilities/Food Assistance Assistance paying for Child Care Free Tax Clinic Purchase Post Secondary Education Homeless Shelter/Soup Kitchen/Food Summer Food Program Help purchase home Weatherize/Insulate home Head Start Preschool Start/Expand Small Business Other

Other

What services did you use at your local Community Action Agency? What services did you use at your local Community Action Agency? Emergency Services (HEAP/PIP/Rent) Publicly Funded Child Care Free Tax Preparation Program Homeless Shelter/Soup Kitchen Summer Food Service Program Financial Empowerment Program Weatherization and Home Repair Programs Head Start Preschool Other

Other

How did these services help you? How did these services help you? This Program saved me money per month in (rent, child care costs, grocery, heating bills, etc.) This program provided me with budgeting, spending, and saving information This program referred me to another agency that helped me Other

Please Explain

Please Explain

Which Agency?

Other

How would it impact you if these services were no longer available?

Any additional comments?