Welcome!

Financial Assessment Form

By working together with us, our goals are:

1. Give you more benefits

2. More options and more control

3. Help you pay less now and in retirement

4. Allow you to retire with 30-40% more income or 30-40% earlier.

5. With less risk than you are currently taking.

6 And... we believe we can do this without taking any money out of your pocket

This form makes this all possible. So please be careful complete this form, and protect this document once it is complete.

The purpose of gathering this information is to:

Help find lazy/unproductive assets, to avoid taking extra money out of your pocket to fund your system

Find inefficiencies where money is leaving your control... unknowingly and unnecessarily (e.g., money spent on taxes, interest, high payments, fees or penalties you don't have to spend),

Identify "no market risk opportunities" within your existing Personal Economic Model where you could use the Financing Strategies we uncover through the process of working together.

Leave blank any information not applicable to you, you don't have, or are uncomfortable providing. While we do not want or need any identifying account numbers, social security numbers, etc., the tax environment of each of your assets is important.

The more complete the information you provide us, the better we are able to advise and consult you on ways to improve your financial position and wealth building.

Let's get started!

First Name

Last Name *

Date of Birth

Phone

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Address

Street Address

City

State

Zip Code *

Please Select Your Time Zone:

Do you have a spouse/ significant other or children?

Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse E-Mail

Spouse Phone Number

Child(ren) Name(s) and Date of Birth

As parents, sometimes we want to help our children pay for college, start a business, etc. Also, we sometimes find it necessary to help our adult children financially, and occasionally opportunities arise where we can "joint venture" a project, down payment on a residanace or participate in a business venture with them.

Health

Currently or previously smoked, or used tobacco or nicotine products?

Self

Spouse

Neither

In the last 5 years have had any hospitalizations?

Self

Spouse

Neither

Had a heart attack, stroke or cancer in the past 5 years?

Self

Spouse

Neither

Do you have any other health conditions?

Self

Spouse

Neither

Been hospitalized overnight for mental health, schizophrenia, or suicidal ideations?

Self

Spouse

Neither

Please use this area to elaborate on any responses:

Employment/Income

What is your current occupation?

Who is your employer?

What kind of work do you do?

When did you start with your current employer?

When do you plan on retiring?

Your Gross Annual Income?

Have you received a bonus in years past? What is the range of your bonuses?

Do you typically receive other income through the year?

Credit Score

Approximate Credit Score

Do You Own a Home?

I rent

Own

Live with family

Home:

Property Type
Current Market Value
Loan Balance
What is the monthly payment on your mortgage?
What year did you purchase your home?
What was the purchase price of your home?
Interest rate
Mortgage Type/ Terms

Do you consider yourself a real estate investor?

Yes, I am a real estate investor

No, but I want to invest in real estate

Are you setting up or have set up a First Position HELOC?

I have a FPHELOC in place

I am setting up my first FPHELOC

No. I do not have a FPHELOC

What is a First Position HELOC?

Primary Residence

I own my home free and clear (no loans of any kind)

True

False

What year was the FPHELOC set up?

How much is your Maximum line of credit?

What is your FP-HELOC or Mortgage interest rate?

How much do you owe on your mortgage(s) and/ or FPHELOC?

How fast is your FPHELOC balance declining every year?

Please provide any additional details on HELOC(s) that would be helpful.

Assets

Please estimate the current amounts:

Checking Account
Savings Accounts
ETF's
CD's
Cash Value Life insurance
Mutual Funds
Bonds
Stocks
Annuities
Business Equity
Alternative Investments
Crypto
Other

Retirement Accounts

Please estimate the current value:

IRA
SEP
Deferred Compensation
Stock Options
401K
Roth 401K
Roth IRA
Self Directed IRA
403b Plan
457 Plan
Pension Balance
Annuity
Other Plan

Pension, Social Security, and Future Income

What age do you plan to start Social Security?

Are you expecting a pension

Yes

At what age does your pension start?

Annually, how much do you think your pension will be?

Future Income or Inheritance

Do you have any expected future income or inheritance?

Liabilities

Please estimate the following values:

Credit Card Debt
Auto Loan(s)
Business Loan
Personal Loan
RV/ Boat Loan
Student Loan
Other Debt

After your monthly bills are paid, how much do you have left over each month?

Protection

Insurance Type:

Please enter any known values:

Purchase Year
Death Benefit
Cash Value (or Accumulation Value)
Annual Premium
Insurance Company

If you have a statement or inforce illustration, please attach here:

Temporary (Term) Insurance

Term Length:

Term Values:

Purchase Year
Death Benefit
Annual Premium
Insurance Company

Please upload any statements or illustrations from your term insurance policy:

Taxes

Please indicate your tax filing status

On last year's taxes, you took:

Please indicate last years combined/ total taxable income

Did you receive a tax refund last year?

Yes

I don't know

If you received a tax refund, approximately how much was it- combined state and federal tax refund:

Will and Trust

Do you have a will?

Yes, I have a will

No, I do not have a will

I don't know if I have a will

When (roughly) was your will last reviewed?

Do you have a trust?

Yes, I have a trust

No, I do not have a trust

I don't know if I have a trust

When (roughly) was your trust last reviewed?

Which aspects of your financial future is most important to you right now?

Paying down debt

Retirement planning

Wealth building

Wealth transfer

What do you see as your greatest financial opportunities

What are your biggest financial concerns?

How can we best help you?

Any other comments?

How did you hear about us/who referred you?

Thank you for taking the time to complete our form. We look forward to meeting with you soon! Please select a date below to meet with our team.