Debt Free Life Intake Form

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PERSONAL INFORMATIONGo grab your most recent financial statements, because we're building you a custom report that will show you how to start building your wealth. Make sure you fill out this entire form as accurately as possible, all the way down to the penny. Remember: this is your report, and garbage in means garbage out.
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Name* This field is required.First & Last Name please.
First Name
Last Name
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Email* This field is required.What's the best email address for us to send you your report?
example@example.com
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Cell Number* This field is required.A phone number that can receive text messages?
Please enter a valid phone number.
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Date of Birth* This field is required.What's your date of birth?
Date
Year
Month
Day
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Address* This field is required.What is your current mailing address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Please select your gender (at birth)* This field is required.
Male
Female
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Are you a smoker?* This field is required.
Yes
No
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MEDICAL INFORMATIONBefore we talk about building your financial freedom, let's make sure we know the best carrier and product to suit your specific health needs.
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Major Medical Issues?* This field is required.Have you had a major medical issues in the past? Cancer, Heart Attack, Stroke, High Blood Pressure, etc...? If you are totally healthy please tell us that too..!
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Taking Medications?* This field is required.Is there anything you take regular medications for?
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How Tall Are You?* This field is required.(example: 5'10")
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Approximate Weight?* This field is required.How much do you currently weigh?
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Married?* This field is required.Are you currently married?
YESNO
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DEBT INFORMATIONWe DO NOT need or want any account numbers or login information. Keep that information to yourself!
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Mortgage?* This field is required.Do you have a mortgage?
YESNO
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How Much Do You Owe?How much money is left on your mortgage?
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Interest %What's the interest rate (APR) on your mortgage?
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Principal Payment per Month?Principal ONLY. DO NOT include interest or escrow amount.
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Monthly Interest Payment?Interest ONLY. DO NOT include principal or escrow amount.
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Paying Any Extra?Do you pay anything extra to your mortgage lender every month?
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Do You Have Credit Card Debt?Any credit card debt?
YESNO
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Please List All of Your Credit Card Debt?If you prefer, feel free to use labels like "Credit Card #1" 1. What's the balance? 2. What is the interest rate? 3. Required minimum payment per month? 4. Do you pay more than the minimum per month? Trying to pay it off quicker?
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Vehicle Loans?Do you have any auto, motorcycle, boat, RV, or other vehicle loans? 1. What's the balance? 2. What is the interest rate? 3. Required minimum payment per month? 4. Do you pay more than the minimum per month? Trying to pay it off quicker?
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Any Other Loans?Personal loans, student loans, etc...? 1. What's the balance? 2. What is the interest rate? 3. Required minimum payment per month? 4. Do you pay more than the minimum per month? Trying to pay it off quicker?
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Ok
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Investment Accounts?For example: Market Portfolios, 401k, 403b, Roth IRA, IRA? Please add a brief description of each account you might have. Example: 401K I have $43000.
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Small
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Ok
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Monthly Expenses?How much does it cost to run your household? If you add up your monthly bills, everything you haven't already listed (mobile phones, cable, Internet, water, electric, groceries, entertainment, etc.), approx. how much is that per month?
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Monthly Income?What is your monthly income after taxes? Include Wages, Rental income, Social Security, Pension, etc.
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Extra Money per Month?After all your bills are paid, is there any money left over at the end of each month as discretionary income?
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Congrats..! All Finished..!Your results have been forwarded to our experts. Thank you for taking the time to fill this out.
Should be Empty: