Bank on LA - City and County of Denver
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Bank on LA Intake Form INTIAL REFERRAL TAB 1. 2. 3. 4. 5. 6. First Name Textbox Last Name Textbox Date of Birth Textbox Phone Number Textbox Zip code Textbox What is your sex? a. Male b. Female 7. Do you have a Bank account? Radio buttons a. Yes b. No 8. Do you have any outstanding loans? a. Yes b. No 9. If so, what is your current level of debt? Textbox 10. Do you have money saved? a. Yes b. No 11. If so, what is your current level of savings? Textbox 12. What is your monthly food expense (estimate)? Textbox 13. Number of people living in your household? Textbos 14. Do you use any of the following financial services? Checkboxes a. Check cashing b. Payday loans c. Money orders d. Western Union/Remittances e. Credit card(s) 15. Who does your taxes? Checkboxes a. Self-prepared b. H&R Block c. Nonprofit d. Other service provider 16. How often do you use financial services? a. More than once a week b. Once a week c. More than twice a month d. Once a month 17. Do you need additional services? Checkboxes a. IRA/Retirement plan b. CD/Higher-interest savings c. Loan d. Credit Card e. Other 18. If other service, please specify Textbox 19. Are you interested in and/or have time to attend any of the following? Checkboxes a. IDA b. Free tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure workshops 20. Do you have Internet access? Radio buttons a. Yes b. No Staff: 1. Was client interested in opening a bank account? Radio buttons a. Yes b. No 2. Did you recommend that he/she open a bank account? a. Yes b. No 3. If so, did he/she a financial institution? Checkboxes a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 4. If other bank, please specify Textbox 5. Did you refer them to or enroll them in any of the following programs? Checkboxes a. IDA b. Tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure prevention 6. Did you go over the Bank on LA brochure with the client? Radio buttons a. Yes b. No 6 MONTH CHECK IN TAB 1. Have you opened a bank account since we last checked-in? a. Yes b. No 2. If so, which bank? Dropdown menu a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 3. Do you have any outstanding loans? a. Yes b. No 4. If so, what is your current level of debt? Textbox 5. Do you have money saved? a. Yes b. No 6. If so, what is your current level of savings? Textbox 7. Which of the following have you used in the past 45 days? Checkboxes a. Bank account b. Check cashing c. Payday loans d. Money orders e. Credit card(s) 8. If you have a bank account, are you comfortable using the bank? Radio buttons a. Yes b. No 9. If you have a bank account, have you had problems with any of the following? Checkboxes a. Minimum balance requirements b. Overdraft charges c. Monthly fees d. Checks clearing e. Using another bank’s ATM f. Other 10. If other, please specify Textbox 11. If you have a bank account, have you used any other service offered at your bank? Checkboxes a. Direct Deposit b. Billpay c. Automatic account transfers d. Remittance 12. Do you need additional services? Checkboxes a. IRA/Retirement plan b. CD/Higher-interest savings c. Loan d. Credit Card e. Other 13. Have you completed any of the following programs? checkbox a. IDA b. Tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure prevention Staff: 1. If client had not opened an account, did you recommend that he/she open an account? 2. If so, did he/she choose a financial institution? Checkboxes a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 3. If other bank, please specify Textbox 4. Did you refer them to or enroll them in any of the following programs? Checkboxes a. IDA b. Tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure prevention 5. If you haven’t already, did you go over the Bank on LA brochure with the client? Radio buttons a. Yes b. No 12 MONTH CHECK-IN TAB 1. Have you opened a bank account since we last checked-in? a. Yes b. No 2. If so, which bank? Dropdown menu a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 3. Do you have any outstanding loans? a. Yes b. No 4. If so, what is your current level of debt? Textbox 5. Do you have money saved? a. Yes b. No 6. If so, what is your current level of savings? Textbox 7. Which of the following have you used in the past 45 days? Checkboxes a. Bank account b. Check cashing c. Payday loans d. Money orders e. Credit card(s) 8. If you have a bank account, are you comfortable using the bank? Radio buttons a. Yes b. No 9. If you have a bank account, have you had problems with any of the following? Checkboxes a. Minimum balance requirements b. Overdraft charges c. Monthly fees d. Checks clearing e. Using another bank’s ATM f. Other 10. If other, please specify Textbox 11. If you have a bank account, have you used any other service offered at your bank? Checkboxes a. Direct Deposit b. Billpay c. Automatic account transfers d. Remittance 12. Do you need additional services? Checkboxes a. IRA/Retirement plan b. CD/Higher-interest savings c. Loan d. Credit Card e. Other 13. Have you completed any of the following programs? checkbox a. b. c. d. e. IDA Tax preparation Financial literacy Credit counseling Homebuyer/foreclosure prevention Staff: 1. If client had not opened an account, did you recommend that he/she open an account? 2. If so, did he/she choose a financial institution? Checkboxes a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 3. If other bank, please specify Textbox 4. Did you refer them to or enroll them in any of the following programs? Checkboxes a. IDA b. Tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure prevention 5. If you haven’t already, did you go over the Bank on LA brochure with the client? Radio buttons a. Yes b. No 18 MONTH CHECK IN TAB 1. Have you opened a bank account since we last checked-in? a. Yes b. No 2. If so, which bank? Dropdown menu a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 3. Do you have any outstanding loans? a. Yes b. No 4. If so, what is your current level of debt? Textbox 5. Do you have money saved? a. Yes b. No 6. If so, what is your current level of savings? Textbox 7. Which of the following have you used in the past 45 days? Checkboxes a. Bank account b. Check cashing c. Payday loans d. Money orders e. Credit card(s) 8. If you have a bank account, are you comfortable using the bank? Radio buttons a. Yes b. No 9. If you have a bank account, have you had problems with any of the following? Checkboxes a. Minimum balance requirements b. Overdraft charges c. Monthly fees d. Checks clearing e. Using another bank’s ATM f. Other 10. If other, please specify Textbox 11. If you have a bank account, have you used any other service offered at your bank? Checkboxes a. Direct Deposit b. Billpay c. Automatic account transfers d. Remittance 12. Do you need additional services? Checkboxes a. IRA/Retirement plan b. CD/Higher-interest savings c. Loan d. Credit Card e. Other 13. Have you completed any of the following programs? checkbox a. IDA b. Tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure prevention Staff: 1. If client had not opened an account, did you recommend that he/she open an account? 2. If so, did he/she choose a financial institution? Checkboxes a. Bank of America b. Bank of the West c. Broadway Federal Bank d. CA Financial Credit Union e. California Bank and Trust f. CalNational Bank g. Cathay Bank h. Citibank i. City National Bank j. Comerica Bank k. Comunidades Federal Credit Union l. Downey Savings m. E1 Financial Credit Union n. EastWest Bank o. First Federal Bank of California p. FirstCity Credit Union q. Hanmi Bank r. Kinecta Federal Credit Union s. OneUnited Bank t. Pacific City Bank u. Pacoima Credit Union v. SCE Federal Credit Union w. Union Bank of California x. United Commercial Bank y. US Bank z. Wachovia aa. Washington Mutual/JPMorgan Chase bb. Water and Power Community Credit Union cc. Wells Fargo dd. WESCOM Credit Union ee. Wilshire State Bank ff. Other 3. If other bank, please specify Textbox 4. Did you refer them to or enroll them in any of the following programs? Checkboxes a. IDA b. Tax preparation c. Financial literacy d. Credit counseling e. Homebuyer/foreclosure prevention 5. If you haven’t already, did you go over the Bank on LA brochure with the client? Radio buttons a. Yes b. No
