Name

Address

Address

Address 2

City/Town

State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

ZIP/Postal Code

Email

Phone Number

Which Issues Are Most Important To You? (Pick 3)

Small Business Support

Education

Housing Development

Social Services

High Utility Bills

Other…

Anti-Semitism

Senior Services

Cost of Living

Public Transportation

Public Safety

Enter other…

What is the Most Frustrating Strain on Your Household Budget Right Now?

Groceries

Mortgage/Rent

Healthcare

Property Taxes

Other…

Childcare/Tuition

Insurance

Enter other…

Agree or Disagree: New York is a Welcoming Place to Raise a Family. (1 Strongly Disagree, 5 Strongly Agree)

Agree or Disagree: New York is a Welcoming Place to Live as a Senior Citizen. (1 Strongly Disagree, 5 Strongly Agree)

Are There Any Other Issues, Projects, Or Community Events You'd Like to See Our Office Prioritize?

How Responsive is Our Office? (1 Very Unresponsive, 5 Very Responsive)

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