Build Wealth MN Application Form

First Name

Last Name

Spouse Name

Street

City

State

Zip

Email Address

Primary Phone

Secondary Phone

Household Size (Including yourself) Household Size (Including yourself)123456789+

Household Annual Income Household Annual Income0 - $10,000$10,000 - $20,000$20,000 - $30,000$30,000 - $40,000$40,000 - $50,000$50,000 - $60,000$60,000 - $70,000$70,000+

Ethnicity EthnicityBlack or African AmericanWhite/CaucasianLatina/MexicanAmerican Indian or Alaska NativeAsianOtherPrefer not to say

Your Age Your AgeYounger than 2020 - 3030 - 4040 - 5050 - 60Older than 60

Do you currently own a home? Do you currently own a home? No Yes

If you own a home, how long have you owned it? If you own a home, how long have you owned it?Less than 1 year1 to 5 years5 to 10 yearsMore than 10 years

If you are behind on your mortgage, how many months? If you are behind on your mortgage, how many months?0123456+

Are you facing foreclosure? Are you facing foreclosure?YesNoNot sure

How many credit cards do you currently have? How many credit cards do you currently have?012345678910+

Do you currently have a budget? Do you currently have a budget? No Yes Not Sure

Have you had formal financial literacy or homeowner education training? Have you had formal financial literacy or homeowner education training? No Yes Don't Recall

What would you like assistance with? What would you like assistance with? Credit Repair Financial Planning Investing and Home Ownership Resources Budgeting Savings Business Technical Assistance

How did you hear about our program?

How would you prefer we contact you? How would you prefer we contact you?Primary Telephone NumberSecondary Telephone NumberEmailOther (please specify below)

If you chose phone, what is the best time to reach you? If you chose phone, what is the best time to reach you? Mornings Afternoons Evenings Weekends

Please enter any additional information or questions