Personal Financial Strategy Worksheet
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1
2Personal Financial Strategy Worksheet
General Information:
Date:_________________________
Client Name #1: ________________________________________
M / F
Age: __________ DOB ____________ /_______/____________
Client Name #2: ________________________________________
M / F
Age: __________ DOB ____________ /_______/____________
Home Address: ______________________________________________ City ____________________ State _________ Zip _______________
Home Phone: ________________________ Cell Phone: __________________________ Email: ______________________________________
Goals:
How confident are you with your current financial strategy?
0
1
2
3
4
5
(Low)
(High)
Check off the most important financial goals in your current situation
o
o
Create a monthly budget
Ensure adequate life insurance coverage
o
Plan for retirement savings
o
o
Payoff credit cards/other debts
Health insurance review
o
Learn about tax free Investments
o
o
Accelerate mortgage payoff
Build a proper emergency fund
o
Grow & Protect my investments
o
o
Consider mortgage refinance
Help child(ren) with college funds
o
Other goals: __________________
If we could help you with 1-3 things financially, what would they be?
1. ______________________________________________________
2. ________________________________________________________
3. ______________________________________________________
Employment & Income:
Client Employer: _______________________________ Yrs _______
Current After-Tax Monthly Income
Client
Spouse
Do you see yourself retiring there?
Y / N
First Income:
_______________
________________
Second Income:
_______________
________________
Client Employer: _______________________________ Yrs _______
Dividends, Interest & Capital Gains:
_______________
________________
Do you see yourself retiring there?
Y / N
Annuities, pensions & Social Security: _______________
________________
Was there a tax refund within the last three years?
Y / N
Income on real property:
_______________
________________
1) $______________
2) $______________
3) $______________
Other:
_______________
________________
Other:
_______________
________________
Will anything change this year?
Y / N
_______________________
TOTAL:
_______________
________________
Monthly Expenses
(*
this section if budgeting is needed):
Complete
__________________________________________________________
How many exemptions do you currently claim on your W-4? __________
Insurance Protection
:
How comfortable are you with your current life insurance coverage?
0
1
2
3
4
5
(Low)
(High)
In the event of an unexpected death, what areas would you like to see your life insurance protect your loved ones against?
o
o
o
Cover final expenses
Replace Income of Breadwinner
Create an education fund for children
o
o
Pay off mortgage balance
Years: breadwinner: _______ spouse _______
Cover Business Debt / Obligations
o
o
o
Pay off remaining debts
Create an emergency fund for survivor
Other: ______________________
o
How would you rate your health?
Client #1:
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5
Client #2:
0
1
2
3
4
5
(Low)
(High)
(Low)
(High)
Do you currently smoke?
Y / N
Have you smoked in the past?
If so, how long ago? _____________________
Person Insured
Insurance Type
Death Benefit
Premium
Company
Term Length
Cash Value
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Parent category: Financial