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| * Are you male or female? |
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| * What is your ethnic background or race? |
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| * In what country were you born? |
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| * What is the highest level of education you've completed? |
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| * In what county do you live? |
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| * Are you a registered voter? |
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| * What is your marital status? |
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| * Do you have any children under age 18 living at home? |
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| * What is your current occupation? | | |
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| * In what year were you born? |
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| * What is your household income (that is a total of everyone's income that lives in your home)? |
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| * Which banking institution do you consider your primary bank? |
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| * Have you been diagnosed with any of the following medical ailments or conditions? |
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| * What is your contact phone number? | | |
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| * What is your email address? | | |
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