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Personal Information
Name
*
First Name
Last Name
Do you have a spouse, name?
Is your spouse
*
Employed
Retired
Business Owner
Homemaker
Not currently employed, but looking
Your date of birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Cell phone number
*
-
Area Code
Phone Number
Work phone number
-
Area Code
Phone Number
Which is your preferred phone?
*
Cell Phone
Work Phone
Personal email
*
Work email
Which is your preferred email?
*
Personal Email
Work Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of contact?
*
Phone
Email
Text
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Page 2 of 5
Current Salary Income
*
Monthly
Spouse Salary Income
Monthly
Are you collecting Social Security?
*
Yes
No
Social Security Income
Monthly
Is your spouse collecting Social Security?
Yes
No
Spouse Social Security Income
Monthly
Disability Income
Monthly
Rental Property Net Income
Monthly
Are you collecting any pension?
Yes
No
Pension income
Monthly
Other Income
Monthly
Description of other income
Other Income
Monthly
Description of other income
Do you have
Mortgage Debt
School Loans
Credit Card Debt
Car Loans
Other
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Page 3 of 5
Housing
Mortgage or Rent
Monthly
Property Tax
Monthly
Electricity
Monthly
Gas
Monthly
Water
Monthly
Sewer
Monthly
Waste Removal
Monthly
Association Dues
Monthly
Cell Phone
Monthly
Home Telephone
Monthly
Internet
Monthly
Cable
Monthly
Package (cable, internet, phone)
Monthly
Home Security
Monthly
Maintenance or Repairs Ongoing
Monthly
Home Repairs Unexpected
Monthly
Supplies (soap, t paper, p towels, cleaning, laundry)
Monthly
Garden Supplies
Monthly
Yard-Gardening-Lawn Service
Monthly
House Cleaning Service
Monthly
Vacation or Rental Property
Monthly
Negative
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
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Page 4 of 5
Transportation
Vehicle 1 Payment
Monthly
Vehicle 2 Payment
Monthly
Public Transportation
Monthly
Fuel
Monthly
Auto Insurance
Monthly
Maintenance
Monthly
License/Tax
Monthly
Parking
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Insurance
Home
Monthly
Health
Monthly
Life
Monthly
Life FEGLI
Monthly
Long Term Care
Monthly
Vision
Monthly
Dental
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
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Daily Living
Groceries
Monthly
Child (Grandchild) Care
Monthly
Dry Cleaning
Monthly
Dining Out
Monthly
Dog Walker
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Children/Grandchildren
Medical
Monthly
Clothing
Monthly
School Tuition
Monthly
School Supplies
Monthly
Organization Dues or Fees
Monthly
Lunch Pocket Money
Monthly
Licensing/Tax
Monthly
Child Care
Monthly
Toys Games
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Entertainment
Video/DVDs
Monthly
CDs
Monthly
Movies
Monthly
Concerts
Monthly
Sporting Events
Monthly
Live Theatre
Monthly
Travel
Monthly
Time Share Maintenance Fees
Monthly
Golf Fees
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
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Family Care
Medical Care (deductibles etc.)
Monthly
Hair/Nails
Monthly
Clothing
Monthly
Health Club
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Pets
Food
Monthly
Medical
Monthly
Grooming
Monthly
Toys
Monthly
Pet Insurance
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Gifts and Donations
Gifts Misc.
Monthly
Birthday Presents
Monthly
Flowers
Monthly
Charity
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Financial Obligations
Personal Loans
Monthly
Credit Card 1 Loan Payment
Monthly
Credit Card 2 Loan Payment
Monthly
Credit Card 3 Loan Payment
Monthly
Federal Tax
Monthly
State Tax
Monthly
Local Tax
Monthly
Social Security
Monthly
Medicare
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
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Savings and Investments
Retirement (TSP, 401k, IRA Roth-IRA etc.)
Monthly
Kids (Grandkids) College
Monthly
Long Time Investments
Monthly
Short Time Investments
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Legal
Attorney
Monthly
Legal Shield
Monthly
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Miscellaneous Payments
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Other
Monthly
Description of other expense
Any other information you feel we should know?
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