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)

Anti-Semitism

High Utility Bills

Public Safety

Cost of Living

Public Transportation

Housing Development

Other…

Small Business Support

Social Services

Education

Senior Services

Enter other…

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

Healthcare

Childcare/Tuition

Groceries

Insurance

Mortgage/Rent

Other…

Property Taxes

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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