Name *
Name
Client Birthday *
Client Birthday
Client Gender *

Name: ________________________________

Phone: _______________________________                         Please submit completed form to:

Email: _______________________________                           Jadelizzi@SecurityPlanningGroup.com


 

Name: M F _______________________________ Birth Date: ___ /___ /_____

Desired Retirement Age: __________

Spouse Name: M F ___________________________ Birth Date: ___ /___ /_______

Desired Retirement Age: __________

Number of Children: ______ Ages_______, ________, ________, ________, _______

State of Issue: 

 

Current Concerns:

  •  Maximizing Savings        
  •  Controlling Spending     
  •  Eliminating Debt        
  •  Wills/Trust
  •  Reducing Taxes        
  •  Asset Protection
  •  Providing for children’s or grandchildren’s education    
  •  Estate Planning

Future Expenditures: _________________________________________________________

________________________________________________________________________________

Real Estate

Personal Residence Information:

Mortgage Payment (P&I only) $__________________

Outstanding Mortgage $______________ Term Remaining ______ years Interest Rate: ______%

Type of Mortgage (check one & circle applicable term)

 Fixed Term (30 year, 15 year, etc.) ARM (5 yr, 7 yr, 10 yr, etc.) Interest Only

Other Property Owned:

Mortgage Payment (P&I only) $__________________

Outstanding Mortgage $______________ Term Remaining ______ years Interest Rate: ______%

Type of Mortgage (check one & circle applicable term)

 Fixed Term (30 year, 15 year, etc.) ARM (5 yr, 7 yr, 10 yr, etc.) Interest Only


Debt Related

Please list any outstanding debts other than mortgages

Name                          Amount Owed      Interest Rate   Minimum Payment   Actual Payment

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

________________ $ ____________ ______%        $ _____________ $_____________

Insurance

Husband Life Insurance

General Health: _________________________________________________________________

Preferred Standard Non-tobacco: Tobacco:

Permanent or Term

Yearly Premium: $_______________ Death Benefit $_______________ Cash Value $_____________

Permanent or Term

Premium: $_______________ Death Benefit $_______________ Cash Value $_____________

Wife Life Insurance

General Health: _________________________________________________________________

Preferred Standard Non-tobacco: Tobacco:

Permanent or Term

Premium: $_______________ Death Benefit $_______________ Cash Value $_____________

Permanent or Term

Premium: $_______________ Death Benefit $_______________ Cash Value $_____________


Income & Expenses

MONTHLY Gross Income Husband          Wife

Wages/Salary $ __________________$ __________________

Social Security $ __________________ $ __________________

Pension $ __________________            $ __________________

Investment Income $ ____________       $ __________________

Rental Income $ __________________ $ __________________

Other Income $ __________________$ __________________

Total Income $ __________________   $ __________________

Desired Retirement Income $________ $___________________

Do you expect a significant change in cash flow in the near future? Yes No

If yes, please explain: ____________________________________________________________________

_____________________________________________________________________________________

Investment Accounts: Non-Qualified Accounts, Qualified Accounts, Savings Accounts

List account type IRA, Roth, 401K, 403b, 457, Savings, etc.

Check the box if the account value, contributions, or both are available

Financial Institution          Account Type    Account Value  Monthly Contribution

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

___________________ __________     $_________ $ __________

Any Asset not listed: ____________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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