Personal Finance Snapshot

Name*

First NameLast Name

Age*

Your E-mail*

Your Phone Number

Area CodePhone Number

Are you single or married?

Spouse's Name*

First NameLast Name

Spouse's Age*

Spouse's Phone Number

Area CodePhone Number

Spouse's Email

example@example.com

Do you have any children or other dependents?*

YesNo

What are your children's and/or dependents' ages? Please list from oldest to youngest

Do you currently work with a monthly budget or spending plan?

YesNo

What areas would you like to discuss?*

Anything you think I should know before the session?

What is your total gross annual household income?*

Your total household earnings before taxes and insurance are withheld.

What is your household monthly take home pay?*

What you are paid out each month after taxes, insurance premiums, and retirement contributions.

Do you have any additional monthly income sources besides work?*

YesNo

Please select the sources from where you receive this income.

What is the total amount you receive from non-employment sources each month combined?

Do you have an emergency fund?*

YesNo

How much in your emergency fund?

Do you regularly contribute to any non-retirement savings or investment accounts?*

YesNo

How much per month do you contribute to this account?

Do you regularly contribute to an Educational Savings Account or a 529 plan? **

YesNo

If yes, how much do you contribute each month?

Do you rent or own your residence?

OwnRent

What is the remaining balance on your mortgage?

Are you current on your payment?*

YesNo

What is your current monthly payment? *

What is the total value of all vehicles in your household?*

Please list each vehicle and its approximate value *

How much cash do you have in all savings accounts?*

What is the total balance of your brokerage investments?*

Non-retirement investments

Do you have money saved in retirement accounts like a 401(k), 403(b), or IRA?*

YesNoOther

How much are you contributing to retirement each month?

What is the total balance of all of your retirement accounts (IRA's, 401k's, pension lump-sum value, etc.)?

Do you own a business?*

YesNo

What type of business?

What is this business's average annual gross revenue?

Do you own rental properties?*

YesNo

What is the approximate total value of these properties?

Do you have non-mortgage debt?*

YesNo

What types of non-mortgage debt do you have? (Mark all that apply and detail applicable amounts below).

Total credit card debt.

Total student loan debt.

Total car debt.

Total personal loans.

Total medical debt.

Total tax debt.

Total HELOC debt.

Total owed on electronic devices.

Total rental property debt.

Total family loans.

If you have any debts not accounted for above, list them here.

When is the last time you pulled a copy of your credit report?*

Within the past 6 monthsWithin the past yearWithin the past 3 yearsMore than 5 years/never have

The following terms apply to the duration of our coaching agreement:

If you are married, I require both husband and wife to attend our appointments. In a married household, both husband and wife must be on the same page for a financial plan to be effective. If your spouse cannot attend at our scheduled time, we will reschedule so that he or she can.

By agreeing to work with me, you understand that my fees are non-refundable and that if you do not show up to your scheduled appointment, you will forfeit your session for the month.

If you need to reschedule, let me know at least 24 hours in advance and I will work with you to find a new appointment time. If we are within the 24-hour timeframe and you cancel, I reserve the right to consider that month’s session forfeited, but will allow room for grace in extreme circumstances.

Lastly, I require you to be an active participant in this process. You will get out of this what you put into it. I devote myself to your well-being in this process, and I require that you devote yourself to that goal as well.

Please verify that you are human*

Personal Information

Income Sources

Savings

Housing

Assets

Debts

Coaching Agreement and Final Submission