Spouse First Name: Spouse Last Name:
Date of Birth:

Children's Names:   Children's Ages:

Rate credit report accuracy:   don't know  poor: fair  good  excellent

FICO Score:

Do you own or rent your home?   Own home free and clear  Own with mortgage  Rent
Years at present residence:   Years Previous residence:
Monthly rent or mortgage payment: Mortgage Balance:
Interest rate:   Market value:
Yes 2nd mortgage  No 2nd mortgage:
2nd Mortgage Balance: 2nd Mortgage Payment: 2nd interest rate:
Car Payment 1:   Interest Rate (car 1):
Car Payment 2:   Interest Rate (car 2):
Car Payment 3:   Interest Rate (car 3):
Credit Card Combined Balance: Total Monthly Credit Card Payments:
Other Debt balance:

Annual Salary:    Spouse Annual Salary:
Other Income :

How would you rate your current savings for an emergency?
don't know  poor: fair  good  excellent

Emergency Fund Balance:  Emergency Fund Monthly Contribution:
Other Savings:

How would you rate your family’s ability to maintain the same standard of living after the loss of a breadwinner?
don't know  poor: fair  good  excellent

Life Insurance Face Amount:   Spouse Face Amount:

How would you rate your current preparations for retirement?
don't know  poor: fair  good  excellent

How would you rate your current use of tax-advantaged investments?
don't know  poor: fair  good  excellent

Total current dollars in all retirement plans: Average interest rate:
Current monthly contributions:

Are you currently using professional money management to build your long-term asset management?  
No     Yes:

Do you have money in CD’s?
No     Yes: CD amount:
Other investments 1:
Amount inv 1:
Other investments 2:
Amount inv 2:
Inheritance in near future:
No     Yes   Inheritance Amount:

Have you or has anyone you know changed jobs recently?     
No     Yes

Phone:  
Address:
Address1:
City:   State:   Zip:
Alternate or Cell Phone:    Fax: