Client A

First Name

Last Name

Phone

Email

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Address

City

State

Postal code

Date of birth

AP008 Age

Employment Information

AE001 Employer/School Name

AE002 School District

AE003 Salary

$

AE004 Hire Date

AE005 Est Date of Retirement

AE007 Side Hustle Income

$

AE006 Yrs of Service at Retirement

AE008 Employment Notes

Retirement Accounts

AR001 Balance 403b

$

AR002 Balance 401k

$

AR003 Balance IRA

$

AR004 Balance 457

$

AR010 Balance Pension

$

AR006 Savings

$

AR007 Checking

$

AR008 Names of Brokerage Firms

AR005 Balance Roth

$

AR009 Retirement Account Notes

Debts/Expenses

AD001 Rent Payment

$

AD002 Car Payment

$

AD003 Car Payments Remaining

AD004 Balance Medical Bills

$

AD005 Past Due Back Taxes

$

AD006 Balance Credit Cards

$

AD007 Balance Student Loans

$

AD008 Any Other Debts

$

AD009 Debt Notes

Insurance

Term

AI001 Term Carrier

AI002 Term Monthly Premium

$

AI003 Term Coverage Amount

$

Perm

AI004 Perm Carrier

AI005 Perm Monthly Premium

$

AI006 Perm Coverage Amount

$

Group

AI007 Group Carrier

AI008 Group Monthly Premium

$

AI009 Group Coverage Amount

$

IUL

AI010 IUL Carrier

AI011 IUL Monthly Premium

$

AI012 IUL Coverage Amount

$

Annuity

AI013 Annuity Carrier

AI014 Annuity Amount

$

AI015 Notes: Reason for Insurance, Beneficiary, Start End Dates etc

Health Qualifications

AH001 Any Major Medical Issues?

AH002 Are You Currently Taking Any Medications?

AH003 Any Tobacco Use?

No

Yes Smoke

Yes Vape

Yes Chew/Pouch

AH004 Height

AH005 Weight

AH006 Health Notes

Motivation

AM001 How Much More Could You Contribute To Your Retirement?

$

AM003 Motivation Notes

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