Financial Goals and Lifestyle Strategy Intake Form

Financial Goals and Lifestyle Strategy Intake Form

Please complete this form to help us understand your financial goals, lifestyle, and planning needs.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PHP Associate
Client Full Name

First NameLast Name
Spouse Full Name

First NameLast Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Anniversary

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent Child 1 Name
Dependent Child 1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent Child 2 Name
Dependent Child 2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent Child 3 Name
Dependent Child 3 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home / Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Federal Tax Refund Last Year
State Tax Refund Last Year
Number of Exemptions
Minimum Amount You Can Save per Month
Maximum Amount You Can Save per Month

Top Financial Goals (Rate 1-10)

Rows	Rate (1-10)
Build retirement wealth
Buy a new home
Finance college for children
Pay off credit cards
Alternate income in case of death or disability
Make a major purchase (car, boat, vacation)
Help support aging parents
Build savings for unexpected expenses

Other Top Financial Goals (please describe)
From the above goals, which 3 are most important to you?
Do you feel you are saving enough for retirement?
What age do you want to retire?
In today’s dollars, how much would you want per month in retirement?
What amount do you feel comfortable saving towards your financial future each month?
Do you currently have life insurance in place for you or your family?
Should be Empty: