Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * MM DD YYYY Race & Ethnicity * White Black or African America American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Household Information Section Number of Adults in Household Household Income (Before Taxes) * Below $25,000 $25,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $249,000 $250,000 - 274,999 $275,000 - 299,999 300,000 + Does your household have health insurance? Yes, Medicare Yes, Private Insurace No Career & Income Section Industry Healthcare and Social Assistance Professional and Business Services Manufacturing Retail Trade Leisure and Hospitality Construction Educational Services Information Technology and Telecommunications Transportation and Warehousing Agriculture, Forestry, Fishing, and Hunting Mining, Quarrying, and Oil and Gas Extraction Financial Activities Utilities Public Administration Other Current Employment Status Full-time employed Part-time employed Unemployed Self Employed Current Monthly Household Income * Have you or anyone in your household experienced a wage increase in the past year? Yes No What challenges are you currently facing in increasing your household income? Entrepreneurship Do you own a business on nonprofit in good standing? Yes No How Long have you filed taxes for this business or nonprofit? 1-3 Years 4-8 Years 9+ Years What is the current size of your business? No employees (solo business) 1 - 5 employees 6 - 10 employees 11 - 25 employees 26 - 50 employees 51 - 90 employees 90 + employees What is your average monthly revenue? * Less than $5,000 $5,000 - $19,999 $20,000 - $59,999 $60,000 - 199,999 $200,000 + Actual Monthly Income What challenges are you currently facing in growing your business? Wealth Do you have any of the following investment or savings accounts? * Traditional Savings Account Retirement Accounts (e.g., IRA, 401(k)) Brokerage/Investment Account Real Estate Investments Other Estimated Value of Investment Accounts * Less than $5,000 $5,000 - $19,999 $20,000 - $59,999 $60,000 - 199,999 $200,000 + Do you own any real estate properties besides your primary residence? Yes No Do you hold any equity or investments in businesses other than your own? Yes No What are your primary goals in building wealth outside of your career or business? * What challenges do you face in building wealth outside of your career or business? * Thank you!
