Passport to Financial Success Application

First Name

Last Name

Mailing Address

Address

City/Town

State/Province

- None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

ZIP/Postal Code

Phone Number

Email Address

Household Size

One

Two

Three

Four

Five

Six or more

Work Status

Employed Full-Time

Unemployed (short-term, 6 months or less)

Unemployed (not in labor force)

Employed Part-time

Unemployed (long-term, more than 6 months)

Retired

Household Income

One or More Sources of Income

No Income

Source of Household Income (choose all that apply)

TANF

Pension

SSI

Social Security

General Assistance

Employment + Other Source

Employment Only

Unemployment Insurance

Other

What is your Approximate Annual Household Income?

Less than $10,000

$10,000-$14,999

$15,000-$24,999

$25,000-$34,999

$35,000-$49,000

$50,000 or above

Housing

Own

Rent

Other Permanent Housing

Homeless

Other

Have you participated in this program before?

Yes

No

Gender

Female

Male

Prefer Not to Say

Age

18-24

25-34

35-49

50-65

65-74

75-years or older

Ethnicity

Hispanic, Latino or Spanish Origin

Not Hispanic, Latino, or Spanish Origin

Race (choose all that apply)

White

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian and Other Pacific Islander

Multi-Race (any two or more from above)

Other

Education level

Grades 0-8

Grades 9-12/Non-Graduate

High School Graduate

GED/Equivalency Diploma

Some College

College Degree

Masters Degree

Doctoral Degree

Other

Health Insurance

Yes

No

Disabled

Yes

No

Military Status

Veteran

Active Military

Never Served in Military

Main Language Spoken at Home

English

Spanish

Other

Are you an employee of the City of Las Cruces?

Yes

No

Are you related to a Las Cruces City employee?

Yes

No

How did you hear about this program?

Submit

Leave this field blank