1.	Date of Birth? (Enter date in mm/dd/yyyy format)

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2.	Where do you live?
	One of the 50 states or the District of Columbia Puerto Rico, Guam, American Samoa, the Northern Mariana Islands or the U.S. Virgin Islands Other No Answer

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3.	Choose the option that best describes your citizenship status:
	U.S. Citizen U.S. National Non-Citizen legally admitted to the U.S American Indian Other No Answer

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4.	What is your gender?
	Female Male No Answer

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5.	What is your race/ethnicity? (check all that apply)
	African American Alaskan Native Amerasian Asian Caucasian Cuban Haitian Hispanic Native American /American Indian Native Hawaiian/Pacific Islander

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6.	Have you ever had to leave your home as a result of a disaster?
	Yes No No Answer

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7.	Are you a victim of a crime that occurred during a disaster?
	Yes No No Answer

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8.	Are you receiving any of the following? (check all that apply)
	Social Security retirement benefits Social Security disability benefits Supplemental Security Income (SSI) benefits Social Security child’s benefits Railroad retirement or disability benefits Medicare Social Security spouse’s or divorced spouse’s benefits Social Security widow or widower’s benefits Social Security parent’s benefits I do not receive any of these benefits

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9.	Which of the following benefits do you receive, or may be eligible to receive? (check all that apply)
	Veterans' disability compensation Veterans' Group Life Insurance Service-Disabled Veterans Insurance (S-DVI) Vocational Rehab Training Servicemembers' Group Life Insurance Specially adapted housing grant DOD tricare(formerly CHAMPUS)

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10.	Are you currently receiving or might be eligible to receive benefits from any of the following programs? (check all that apply)
	Food Stamps Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Temporary Assistance for Needy Families Unemployment Benefits Medicaid Federal Pell Grant A private traditional pension plan that has ended

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