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Source(s) of [ncome iu die last 30 days: (Cheek all that apply) <br />Earoed lncotne (Joh) Social Scx:uriry <br />AFDC/TANF Food Stamps <br />General Assistance (GA) Retatives/parmer/friends <br />Unernployrnart Compettsatiou\SDI Panhartdliug/Vouchers <br />Vocational Programs Otlrer Sources of Income: <br /> (Please describe) <br />SSI <br />VA Pettsiou <br />Srllitg carts <br />Retirement <br />If unemployed, are you seeldrtg work: Yes No How loiig7 <br />In die last month what services have you used? (Check as many as apply) <br />Received ,Waiting List Received Waititg List <br />Food/Hot Meals Shelter <br />Health Care Domestic Violence <br />Job Help Storage - <br />Sltowers Transitional Housitg <br />Drop-it Center Respite care <br />Alcohol/Dn-g Sus ticket <br />Rehab Shelter Plus Care <br />Section 8 Pennaneut Rental Assistance _ <br />Housitg <br />In what cities do you use service dte tnost7 (1) (2) (3) <br />Irt the last 7 days, how did you mostly get around'? (Check two answers only) <br />Walked Drove my ow» czar <br />Caught the bus BART <br />Used taxi scrip Used awheelchair/other nutbility device <br />Got a ride from friend or family Bus tickets <br /> Bicycle <br />How did you pay for the fare for your Last ride ott Public Transit'? <br />Cash Scrip Fast Pass Bus Tickets <br />What services do you need that you arc not gettitg? <br />What would leave prevented you from becoming homeless? <br />How big an aparnnent/house do you needy Studio lbdnn _ <br />3 bdnn 4+bdnn <br />Where do you want to live? (List three choices) <br />(I) (2) (3)) <br />2bdnn <br />PLEASE RETURN SURVEY FORMS TO: EMERGENCY SERVICES NETWORK <br />P.O. BOX 12004, OAKLAND, CA 94fa04 <br />TEL: (510)451-3118 /FAX: (510)451=3144 <br />G:~HOMELESS\CO FCISUR V EYS. KNG <br />