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51 <br /> ATTACHMNT I <br /> Orange County <br /> Welfare Reform Task Force <br /> I. Let's talk about you... <br /> 1) ❑ Male ❑ Female <br /> 2) Age: 3) Race/Ethnicity: <br /> ❑ 16 or younger ❑ African American <br /> ❑ 17-21 ❑ Asian <br /> ❑ 21-30 ❑ Caucasian <br /> ❑ 30-40 ❑ Latino <br /> ❑ 40-50 ❑ Native American <br /> ❑ over 50 ❑ Other <br /> 4) Are you a single parent? ❑ Yes ❑ No <br /> 5) Are there children or adults in your household that depend on you for care? <br /> ❑ Yes ❑ No <br /> II. Let's talk now about your household: <br /> 6) How many children live in your home? How many adults live in your <br /> home ? <br /> 7) What are the ages of the children who live in your home? <br /> 8) What is your family's main source of income? <br /> ❑ Employment ❑ Child Support <br /> ❑ Public Assistance ❑ Other <br /> 9) What is your family's average(net)monthly income? <br /> ❑ $0-$499 ❑ $500-$999 ❑ $1,00041,499 ❑ $1,50041,999 <br /> ❑ $2,000-$2,999 ❑>$3,000 <br /> 10) Have the adults who are parents(including you) in your house completed any of the <br /> following? <br /> Mother Father <br /> ❑ high school ❑ ❑ <br /> ❑ college ❑ ❑ <br /> ❑ GED ❑ ❑ <br /> 11) Do you have a telephone? ❑ Yes ❑ No <br /> 12) What do you call your community? <br />