GOALS What are your three most important financial goals? Client: Spouse: A. A. B. B. C. C. What are your three most important personal goals? Client: Spouse: A. A. B. B. C. C. What would you like for Freedom 5:one Ministries to help you accomplish? Freedom 5:one Ministries 2894 McKee Circle Suite 112 Fayetteville, AR 72703
Date FAMILY Client Spouse Name Birthday Age Children/Dependents Living at home Yes or No Mailing Address City State Zip Home Phone E-Mail Cell Phone Cell Phone (Circle one) Single Married Divorced Widowed Do you have a Will? When was it last reviewed? Do you have a Trust? When was it last reviewed? Where do you attend Church? How Long? Employer Occupation Employer Address Work Phone How long have you been with current employer? Previous Occupations Spouse s Employer Occupation Employer Address Work Phone How long have you been with current employer? Previous Occupations 1
INCOME The following information should be taken from your payroll stub. (please bring pay stub) If you are Self-Employed (skip this page) Enter income and tax information on Page 6 1 st Earner How often do you get paid? 2 nd Earner How often do you get paid? Weekly Bi-Weekly Semi-Monthly Monthly Weekly Bi-Weekly Semi-Monthly Monthly Gross per Paycheck Gross per Paycheck D Federal D Federal E State E State D Soc.Sec./FICA/OASDI D Soc.Sec./FICA/OASDI U Medicare U Medicare C Medical Reimbursement C Medical Reimbursement T Health Ins. T Health Ins. I Dental Ins. I Dental Ins. O Cancer Ins. O Cancer Ins. N Vision Ins. N Vision Ins. S Life Ins. S Life Ins. Dependent Life Dependent Life AD&D AD&D Disability ST Disability ST Disability LT Disability LT Other Ins. Other Ins. Retirement/401k Retirement/401k Savings Savings Stock Purchase Stock Purchase Loan Payment Loan Payment Garnishment Garnishment Charities Charities Christmas Club Christmas Club Fitness Center ALL OTHER INCOME MONTHLYFitnessCenter Child Support Child Support Child Care Reimbursement Child Care Reimbursement Other Other Take Home per Paycheck Take Home per Paycheck OTHER INCOME Bonus Other Child Support Commission Tax Refund 2
Medical Insurance INSURANCE PD if premiums are payroll deducted Insured Insurance Company Deductible Type Premium PD Co-Pay Amount Frequency Life Insurance Insured Insurance Company Face Amount / Type Premium PD Cash Value Amount Frequency What do you want your life insurance to cover? (Circle all that apply) Survivor Income Final Expense Pay off mortgage Pay off consumer debt Fund College Disability Insurance Insured Insurance Company Mo.Benefits/ Short Term or Premium PD Waiting Period Long Term Amount Frequency Long Term Care Insurance / Dental / Cancer / Critical Illness Insured Insurance Company Benefit/ Type Premium PD Deductible Amount Frequency Liability Insurance What is the liability limits on your auto policy? What is the liability limit on you home policy? Do you have a umbrella liability policy? What is the limit? Client: Ht. Wt. use tobacco? yes no 3
Pre existing conditions/medications Spouse: Ht. Wt. use tobacco? yes no Pre-existing conditions/medications Children: Pre-existing conditions/medications SAVINGS Checking Acct., Savings Acct., Money Market Acct. CD s, etc. PD if savings is payroll deducted Type Current Value Client Frequency PD Contribution of Contribution RETIREMENT/INVESTMENT ASSETS 401k, 403b, IRA, Roth IRA, Annuity, Mutual Funds, Stocks, etc. Expected Retirement Age Type Current Client Employer Frequency PD Value Contribution Contribution of Contribution 4
Estimated Social Security Benefit Client: Spouse: At age 62 At age 62 At age At age Estimated Pension Benefit Client: Spouse: At age At age Cost of living adjustment Survivor Benefit Cost of living adjustment Survivor Benefit Do you plan to pay for or assist with children s college cost? Yes or No Where? Please describe plan: Are you expecting an inheritance? Please describe it: Real Estate Description Creditor ASSETS % Current Outstanding Minimum Pmt. You re Interest Value Loan Payment Making How long to you expect to live at current residence? Interest Rate Fixed or Variable Do you have credit life on your home mortgage? Number of Years Financed Number of Years Remaining on Mortgage Vehicles Other Assets (i.e. Boat, RV, Motorcycle, Jet ski, Livestock, etc,) 5
MONTHLY EXPENSES Do Not Include Payroll Deductions Childcare: MEDICAL DEBT Child Support: @Doctor: List on Debt page Tithe/Contribution: @Dentist: @Optometry: HOUSING @Medicine: Retirement: House Payment: INSURANCE @Specified: Rent: Health: Investments: Cable: Life: @Car Fund: SAVINGS Water & Trash: Disability: @Uncommitted: Electric: Misc. Insurance: Gas: @Insurance Setback: @CLOTHING: @Propane/Wood: Phone: ENTERTAINMENT GIFTS Housekeeper: @Vacation/Trips: @Christmas: @Insurance & Taxes: @Camps: @Gifts: @Home Maintenance: $Entertainment: Celluar Phone: @Sports/Activities: SCHOOLING Alarm System: Fitness Center: Tuition/Expenses (Monthly): $GROCERIES: MISCELLANEOUS Lessons: AUTO $Spending: School Lunch (Paid Check): @Tuition/Exp. (Setback): Auto Payment 1: $Wal-Mart: Extras Auto Payment 2: Hair Cuts/Cosmetics: Misc. @Auto Insurance (Setback) Subscriptions: Misc. Auto Insurance (Monthly) Dry Cleaning: $Cash Acct. $Gasoline: Internet Service: $Cash Acct. @Maintenance: @Pets: @Setback @Tags/Taxes: Stamps: @Setback Bank Fees: Instructions: Figure each category and enter the amount into the blank. This is a monthly plan. Everything should be broken down into a monthly figure. Example: $25 week x 52 12 = $108.33 monthly $25 bi-weekly x 26 12 = $54.17 monthly $25 semi-monthly x 2 = $50.00 monthly 6
DEBT Include Credit Cards, Consolidation Loans, Loan from Parents, Medical Bills, 401k Loans, Etc. List them even if you are not making payments. PD if payment is payroll deducted Consumer Debt Creditor % Outstanding Minimum Pmt. You re PD Interest Balance Payment Making @Debt Setback: TOTAL DEBTS @ Debt Setback is for debts you pay on a quarterly or annual basis. 7
SELF-EMPLOYED INCOME Client Spouse Last year s avg mo. personal income after expenses Current year est. mo. personal income after expenses. How often do you pay yourself? Are you paying taxes on a quarterly basis? Yes or No Yes or No Amount of estimated quarterly taxes. (Circle one) Sole Proprietor Partnership S Corp C Corp Number of Employees Do you Provide employee benefits? Yes or No If (Yes) List Benefits and Providers: Do you maintain separate accounts for personal and business finances? Yes or No Other Business related information: 8