Screening for financial assistance provided by: National Abortion Federation Screening For NAF First Name * Last Name * Date of Birth * Email Address * Do you have health insurance? * Yes No If you do have health insurance, what type: How many people live in your home? * What is your total household income? (Please include all money from all household members) * Do you receive any food assistance (SNAP)? * Yes No If you do receive food assistance, how much monthly? Do you receive child support? * Yes No If you do receive child support, how much monthly? Does anyone help you pay bills? * Yes No If you do have help with your bills, how much monthly? What city do you live in? * ZIP Code * Phone * Race: * If you are human, leave this field blank. Submit
National Abortion Federation