Personal Financial Snapshot
Appointment Date
*
-
Month
-
Day
Year
Date
Your Name
*
First Name
Last Name
Your Age
*
Your Type of Work/Employment
*
Your Spouse's Name
*
First Name
Last Name
Spouse's Age
*
Spouse's Type of Work/Employment
*
Number of children or other dependents
*
Have you been through FPU?
*
Yes
No
What is FPU?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Preferred Method of conducting your session(s):
In Person
Via Telephone
Via Virtual Video Conference
Income
What is your monthly net take-home pay?
*
Example: $3,000
What is your spouse's monthly net take-home pay?
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Example: $3,000
Do you have irregular income (meaning your income changes monthly?
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Yes
No
Do you use a monthly budget?
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Yes
No
Savings
Do you have an emergency fund?
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Yes
No
How much is in the fund?
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Example: $1,000
Are you currently investing for retirement?
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Yes
No
If so, what is the current balance?
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Example: $1,000
If so, what is your monthly contribution?
*
Example: $250
Do you contribute to non-retirement savings?
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Yes
No
If so, what is the current balance?
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If so, what is your monthly contribution?
*
Housing
Do you rent or own?
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Rent
Own
If you own, what is the loan balance?
*
Example: $100,000
Are you current on your payment?
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Current
Behind on Payments
How much do you pay total each month?
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Example: $1,250
Consumer Debt
Do you have any vehicle loans?
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Yes
No
If so, are you current on the vehicle payments?
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Yes
No
What are your total monthly vehicle payments?
*
Example: $650
Other Consumer Debt
(Please Provide Total Balances of Each Type)
Credit cards?
*
Balance Owed
Student loans?
*
Balance Owed
Payday loans?
*
Balance Owed
Signature loans?
*
Balance Owed
Taxes owed?
*
Balance Owed
Other Types of Loans (Not Previously Listed)?
*
Balance Owed
What primary financial concerns should we focus on during your coaching session?
Chose One
Budgeting
Debt Elimination
Retirement
Wealth Building / Investing
Funding College Education
Dealing with Collectors
Other
List the top 3 concerns with your primary choice above.
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If you were at the end of your life and looking back over it, what would you be most proud of and what would you regret?
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Please verify that you are human
*
Submit
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