Financial Coaching, SparkPoint, Community Action Marin

SparkPoint Coaching Member Information

SparkPoint Baseline Form

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There are three steps to becoming a SparkPoint member:
1. You will receive an email with a link to a Welcome Form for you to complete online. Please complete this form in its entirety.
2. Please complete the Baseline Form below to the best of your ability.
3. A staff member will contact you to schedule your first coaching appointment.

If you prefer paper copies of these forms, we will mail them to you or you may pick them up at our office at 555 Northgate Drive, Suite 201, San Rafael.

Completed paper forms may be submitted via any of these methods:

1. Email: clientintake@camarin.org (preferred method)
2. Postal Mail: 555 Northgate Dr., Suite 201, San Rafael, CA 94903
3. Fax: 415.457.9677
4. Drop-off Box: Our office is located at 555 Northgate Drive, San Rafael. The drop box can be found at the back of the building on the parking lot side, to the left of the double door entrance (not street side).

If you are unable to complete the Baseline Form on your own, please come to your first appointment prepared with the information on this document checklist.

For assistance completing this process, please contact us at clientintake@camarin.org or 415.526.7500.

Step 1Employment & Education

Step 2Income, Housing, & Benefits

Step 3Assets, Debt, Expenses, & Credit

EMPLOYMENT & EDUCATION

Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone Number(Required)

EMPLOYMENT INFORMATION

If you have more than one job, please complete all of the information for each job separately.

Are you employed? If yes, complete the fields below.

Yes

Employer #1:

Employer #1 Zip Code

Employer #1 Position:

Full Time

Part Time

Self Employed

Employer #1 Hours Worked Per Week

Employer #1 Pay: $/Hour

Employer #1 Industry Type

Employer #1 Position Type

Employment #1 Employment Type

Permanent

Temporary

Contract

Seasonal

Employer #1 Start Date

MM slash DD slash YYYY

Employer #1 End Date

MM slash DD slash YYYY

Would you like to add a 2nd employer? (Skip if not)

Add 2nd employer

Employer # 2:

Employer #2 Zip Code

Employer #2 Position:

Full Time

Part Time

Self Employed

Employer #2 Hours Worked Per Week

Employer #2 Pay: $/Hour

Employer #2 Industry Type

Employer #2 Position Type

Employment #2 Employment Type

Permanent

Temporary

Contract

Seasonal

Employer #2 Start Date

MM slash DD slash YYYY

Employer #2 End Date

MM slash DD slash YYYY

Would you like to add a 3rd employer? (Skip if not)

Add 3rd employer

Employer # 3:

Employer #3 Zip Code

Employer #3 Position:

Full Time

Part Time

Self Employed

Employer #3 Hours Worked Per Week

Employer #3 Pay: $/Hour

Employer #3 Industry Type

Employer #3 Position Type

Employment #3 Employment Type

Permanent

Temporary

Contract

Seasonal

Employer #3 Start Date

MM slash DD slash YYYY

Employer #3 End Date

MM slash DD slash YYYY

EDUCATION & TRAINING INFORMATION

Are you enrolled in school/training?

Yes

Institution #1

Institution #1 Major/Certification Name

For Institution #1, is your schooling:

Full Time

Part Time

For Institution #1, what is the number of units:

Institution #1 Degree/Certificate Type:

Certificate

AA/AS Degree

BA/BS Degree

Institution #1 Degree/Certificate Received:

Yes

For Institution #1 Degree/Certificate Status:

Completed

In Progress

Transferred

Withdrew

Other

Institution #1 Start Date

MM slash DD slash YYYY

Institution #1 End Date

MM slash DD slash YYYY

Would you like add additional schooling/training? (Skip if not)

Add additional schooling/training

Institution #2

Institution #2 Major/Certification Name

For Institution #2, is your schooling:

Full Time

Part Time

For Institution #2, what is the number of units:

Institution #2 Degree/Certificate Type:

Certificate

AA/AS Degree

BA/BS Degree

Institution #2 Degree/Certificate Received:

Yes

For Institution #2 Degree/Certificate Status:

Completed

In Progress

Transferred

Withdrew

Other

Institution #2 Start Date

MM slash DD slash YYYY

Institution #2 End Date

MM slash DD slash YYYY

Would you like add additional schooling/training? (Skip if not)

Add additional schooling/training

Institution #3

Institution #3 Major/Certification name

For Institution #3, is your schooling:

Full Time

Part Time

For Institution #3, what is the number of units:

Institution #3 Degree/Certificate Type:

Certificate

AA/AS Degree

BA/BS Degree

Institution #3 Degree/Certificate Received:

Yes

For Institution #3 Degree/Certificate Status:

Completed

In Progress

Transferred

Withdrew

Other

Institution #3 Start Date

MM slash DD slash YYYY

Institution #3 End Date

MM slash DD slash YYYY

INCOME, HOUSING, & BENEFITS

Personal and Housing Information

How many people in the following age ranges live in your household, including yourself?

Please include everyone you share expenses with and are financially responsible for.

Infants (0-2 Years)

Preschoolers (3-5 Years)

School-Age Children (6-12 Years)

Teenagers (13-17 Years)

Adults (18+)

For households with children in school K - 12, did any children transfer to a new school recently?

Yes

If yes, please indicate the reason or reasons for the transfer.

Transitioned from elementary school to middle school

Transitioned from middle school to high school

We moved to a different neighborhood and the school transfer was planned

We moved to a different neighborhood and the school transfer was NOT planned and was disruptive for my child

I worked with the district to transition my child out of their school and to a different school that better met their special needs (the district or school helped make this a smooth transition)

How would you describe your housing situation?

Please select the option that best applies to you. (select one option only)

How would you describe your housing situation?

Living in home (as owner)

Living in home (as renter)

Living in subsidized home (such as Section 8)

Living with family or friends with no plans to move

Living in shelter, vehicle, or temporary housing

Currently without housing

Prefer not to answer

Other

If you own a home, what is the estimated value?

If you received an eviction notice, please indicate the date received below.

MM slash DD slash YYYY

Monthly Average Earned Income

Your monthly earned average gross income:

Other household members earned average gross income:

Total Earned Income

Monthly Other Sources of Income

Do you or anyone else in your household have other sources of income? If yes, please check all that apply and enter the amount you receive each month.

Child Support

Alimony

Investment

Pension

Scholarship

Workers' Comp

Any other income

Child Support

Alimony

Investment

Pension

Scholarship

Workers Comp

Any Other Income

Total Other Source Income

Monthly Public Benefits Received

Do you or anyone else in your household receive public benefits or other sources of income? If yes, please check all that apply and write in the amount you receive each month.

CalFresh/SNAP

CalWORKS/TANF

CARE

General Assistance

Head Start

Lifeline Telephone Bill Assistance

Medi-Cal

Medicare

School Lunch

Social Security/SSDI, SSI, SDI

Subsidized Childcare

Unemployment

Utilities/HEAP

Veteran's Benefits

WIC

All Other Benefits

CalFresh/SNAP

CalWORKS/TANF

General Assistance

Social Security/SSDI, SSI, SDI

Unemployment

Utilities/HEAP

Veterans Benefits

All Other Benefits

Total Public Benefits

Student Financial Aid

Do you or anyone else in your household receive any student financial aid? If yes, please write in the amount you receive annually for each item listed below.

Yes

Cal Grant

Pell Grant

Other Scholarship

ASSETS, DEBT, EXPENSES, & CREDIT

Savings & Assets Information

Do you have any of the following accounts? If so, please check all that apply and enter your total balance in the spaces below.

Checking

Cash Savings

Prepaid Debit Card

Savings

Stipend

Individual Development Account (IDA)

Retirement Account

Investments

Education Fund (Self or Children)

All Other Accounts

Checking

Cash Savings

Prepaid Debit Card

Savings

Stipend

Retirement Account

Individual Development Account (IDA)

Investments

Education Fund (Self or Children)

All Other Accounts

Total Savings

If you own a vehicle, what is the estimated value? (Skip if you do not own a vehicle.)

Debt Information

Please fill in the total balance and minimum monthly payment due for all those that apply below.

Credit Card #1 Name

#1 Total Balance

Minimum Monthly Payment Due

Would you like to add another credit card?

Add another credit card

Credit Card #2 Name

#2 Total Balance

Minimum Monthly Payment Due

Would you like to add another credit card?

Add another credit card

Credit Card #3 Name

#3 Total Balance

Minimum Monthly Payment Due

Would you like to add another credit card?

Add another credit card

Credit Card #4 Name

#4 Total Balance

Minimum Monthly Payment Due

Would you like to add another credit card?

Add another credit card

Credit Card #5 Name

#5 Total Balance

Minimum Monthly Payment Due

Do you have any of the following debt? If so, please check all that apply and enter the total balance and minimum monthly payment due in the spaces below.

Personal Loan (friend or relative)

Student Loans

Mortgage

Vehicle Loan

Medical Debt

Back Taxes

Payday Lender

Utilities Debt

Child Support

Collections Debt

All Other Debt

Personal Loan Balance (friend or relative)

Minimum Monthly Payment Due

Student Loan Balance

Minimum Monthly Payment Due

Mortgage Balance

Minimum Monthly Payment Due

Vehicle Loan Balance

Minimum Monthly Payment Due

Medical Debt Balance

Minimum Monthly Payment Due

Back Tax Balance

Minimum Monthly Payment Due

Payday Lender Balance

Minimum Monthly Payment Due

Utilities Debt Balance

Minimum Monthly Payment Due

Child Support Owed

Minimum Monthly Payment Due

Collections Debt Balance

Minimum Monthly Payment Due

All Other Debt

Minimum Monthly Payment Due

Total Debt Balance

Total Minimum Monthly Payment Due

Average Monthly Expenses

Please fill in your monthly expenses for all fields. If you do not have expenses in an area, please write "0".

1. Housing & Utilities

Rent

Phone

Electricity/Gas

Water/Sewer

Cable/Internet

Garbage/Waste Removal

Maintenance & Repairs

Home/Renter's Insurance

Property Tax

Homeowner's Association Fees

All Other Housing Costs

Subtotal Housing & Utilities

2. Food

Groceries

Dining Out

Subtotal Food

3. Transportation

Public Transportation/Taxi

Auto Insurance

Car Share or Rental

Fuel

Maintenance

Subtotal Transportation

4. Medical/Dental Costs

Prescriptions

Health Insurance

Out of Pocket

Subtotal Medical & Dental

5. Education

If you or your spouse are in school, please indicate monthly expenses for you both.

Monthly Fees & Tuition

Monthly School Supplies

Subtotal Education

6. Children

Childcare

Children School Tuition

Children School Supplies

Toys/Games

Clothing

Child Support

All Children Other Costs

Subtotal Children

7. Other Expenses

Legal

Donations

Pet Costs

Entertainment

Personal Care (clothing, hair, etc.)

Remittance (money you send home)

Miscellaneous

Subtotal Other Expenses

8. Taxes Paid Monthly (from pay stub)

Federal

State

Local

Social Security

Subtotal Taxes Paid Monthly

Total Expenses

Sum of Expense Subtotals

Sum of Minimum Monthly Payments

Total Expenses

Credit Score Information

Do you know your credit score (FICO) from Equifax?

Yes, I know my score

No, I don't have enough credit history to have a score

No, I don't know my score

Please enter your Equifax (FICO) score here:

Do you know your credit score (FICO) from Experian?

Yes, I know my score

No, I don't have enough credit history to have a score

No, I don't know my score

Please enter your Experian (FICO) score here:

Do you know your credit score (FICO) from TransUnion?

Yes, I know my score

No, I don't have enough credit history to have a score

No, I don't know my score

Please enter your TransUnion (FICO) credit score here:

Financial Well-Being

How well does this statement describe you or your situation?

	Completely	Very Well	Somewhat	Very Little	Not at All
Because of my money situation, I feel like I will never have the things I want in life.
I am just getting by financially.
I am concerned that the money I have or will save will not last.
I have money leftover at the end of the month.
My finances control my life.

Pease complete our form below

SparkPoint Baseline Form

EMPLOYMENT & EDUCATION

EMPLOYMENT INFORMATION

EDUCATION & TRAINING INFORMATION

INCOME, HOUSING, & BENEFITS

Personal and Housing Information

How many people in the following age ranges live in your household, including yourself?

How would you describe your housing situation?

Monthly Average Earned Income

Monthly Other Sources of Income

Monthly Public Benefits Received

Student Financial Aid

ASSETS, DEBT, EXPENSES, & CREDIT

Savings & Assets Information

Debt Information

Average Monthly Expenses

1. Housing & Utilities

2. Food

3. Transportation

4. Medical/Dental Costs

5. Education

6. Children

7. Other Expenses

8. Taxes Paid Monthly (from pay stub)

Total Expenses

Credit Score Information

Financial Well-Being