Data Information Sheet
The following information is needed to complete your custom Debt Report.
We do not need any private information, account numbers, social security numbers, etc. Be as specific as you can so we can get you to most accurate report and projections.
First Name
*
Last Name
*
Email
*
Date of birth
*
State
*
Desired Retirement Age
*
Spouse Name
Birth Date Spouse
Desired Retirement Age Spouse
Number of Children
Ages of Children
Financial Concerns
Check all that apply...
Controlling Spending
Eliminating Debt
Reducing Taxes
Creating your own Family Bank
Asset Protection
Maximizing Savings
Estate Planning
Providing for children or grandchildren's education
Will/Trusts
Future Expenditures
Click Next ⬇️
Real Estate Information
Personal Residence Information
Mortgage Payment (Principal & Interest)
Mortgage Outstanding balance:
Mortgage Interest Rate:
Type of Mortgage
Fixed Term (30/15/etc
Adjustable Rate
Interest Only
Balloon
Other Property Owned
Other Mortgage Payment
Other Outstanding Mortgage Balance
Other Mortgage Interest Rate
Other Mortgage Type
Fixed Term
ARM
Interest Only
Balloon
Debt Information
Try and be as specific as possible, but a rough estimate will be fine. Once you've submitted all your debts scroll to bottom of page and click next...
Debt #1
Debt 1 Name
Debt 1 Amount Owed
Debt 1 Interest Rate
Debt 1 Minimum Payment
Debt 1 Actual Payment
Debt #2
Debt 2 Name
Debt 2 Amount Owed
Debt 2 Interest Rate
Debt 2 Minimum Payment
Debt 2 Actual Payment
Debt #3
Debt 3 Name
Debt 3 Amount Owed
Debt 3 Interest Rate
Debt 3 Minimum Payment
Debt 3 Actual Payment
Debt #4
Debt 4 Name
Debt 4 Amount Owed
Debt 4 Interest Rate
Debt 4 Minimum Payment
Debt 4 Actual Payment
Debt #5:
Debt 5 Name
Debt 5 Amount Owed
Debt 5 Interest Rate
Debt 5 Minimum Payment
Debt 5 Actual Payment
Debt #6:
Debt 6 Name
Debt 6 Amount Owed
Debt 6 Interest Rate
Debt 6 Minimum Payment
Debt 6 Actual Payment
Debt #7:
Debt 7 Name
Debt 7 Amount Owed
Debt 7 Interest Rate
Debt 7 Minimum Payment
Debt 7 Actual Payment
Life Insurance Information
Husband Life Insurance
Do you have life insurance?
*
Yes
No
Husband Life Insurance Information
Is it permanent or term?
Permanent
Term
Death Benefit Amount
Yearly or Monthly Premium?
Cash Value
General Health
Do you use tobacco of any kind?
Yes
No
Wife Life Insurance
Do you have life insurance? (Wife)
*
Yes
No
Wife Life Insurance Information
Is it permanent or term? (Wife)
Permanent
Term
Death Benefit Amount (Wife)
Yearly or Monthly Premium (Wife)
Cash Value (Wife)
General Health (Wife)
Do you use tobacco of any kind? (Wife)
Yes
No
Income & Expenses
* These are gross numbers (before taxes)
HUSBAND INCOME (GROSS)
Husband Wages/Salary
Husband Social Security
Husband Pension
Husband Investment Income
Husband Rental Income
Husband Other Income
Husband Total Income
WIFE INCOME (GROSS)
Wife Wages/Salary
Wife Social Security
Wife Pension
Wife Investment Income
Wife Rental Income
Wife Other Income
Wife Total Income
Retirement Income Goals
Husband Desired Retirement Income
Wife Desired Retirement Income
Do you expect a significant change in cash flow in the near future?
Yes
No
If expect change in cash flow, please explain:
Investment Accounts
We DO NOT need account #'s or any private information. List account type (IRA, Roth, 401k, 403b, 457, Savings, etc) Check the box if the account value, contributions, or both are available
Financial Institution #1:
Account 1 Type:
Account 1 Value:
Account 1 Monthly Contribution:
Do you have another investment account?
Yes
No
Investment Account #2
Financial Institution #2:
Account 2 Type:
Account 2 Value:
Account 2 Monthly Contribution:
Do you have a third investment account?
Yes
No
Investment Account #3
Financial Institution #3:
Account 3 Type:
Account 3 Value:
Account 3 Monthly Contribution:
Do you have a fourth investment account?
Yes
No
Investment Account #4
Financial Institution #4:
Account 4 Type:
Account 4 Value:
Account 4 Monthly Contribution:
Do you have a fifth investment account?
Yes
No
Investment Account #5
Financial Institution #5:
Account 5 Type:
Account 5 Value:
Account 5 Monthly Contribution:
Do you have a sixth investment account?
Yes
No
Investment Account #6
Financial Institution #6:
Account 6 Type:
Account 6 Value:
Account 6 Monthly Contribution:
Do you have a seventh investment account?
Yes
No
Investment Account #7
Financial Institution #7:
Account 7 Type:
Account 7 Value:
Account 7 Monthly Contribution:
Success! You've taken the first step to financial freedom from the burden of debt. By taking this first step you have separated yourself from the majority of people. Congratulations!
It usually takes 48 hours to get back your report. At that time we will call or email you to set up a time to review it. I certify that the information given is true to the best of my knowledge and will be used to create a personal Big Picture Report.
Signature
Clear
Date Signed:
Click Submit ⬇️
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