Financial Needs Analysis
[Company Name] · Agent-guided intake
Step
1
of 2
Section A — What Matters to You
What are some of the things that are important to you that cost money?
1.
2.
3.
4.
5.
6.
How much income would it take to live the life you just described?
How long will it take before you earn the income you need to live that life?
If your job/profession won't allow you to realize your dream life, what's more important to you: staying in your job/profession or leading your ideal life?
Section B — General Information
Does the client have a spouse/partner?
Yes
No
Client
*
Name
*
Sex
M
F
Age
Date of Birth
Do you currently use tobacco or nicotine products on a regular basis?
*
Yes
No
*
SSN (last 4 digits)
Home Address
City
State
Select
Zip
Home Phone
Cell Phone
*
Email
*
Work Address
City
State
Select
Zip
Work Phone
Fax
Work Email
Any dependents?
Yes
No
Section C — Goals & Dreams
If I could help you reach your top financial goals, what would they be?
Short-term (1–3 years)
Car
Furniture
Boat
Family vacation
Build retirement wealth
Buy a new home
Alternate income in case of death or disability
Build savings for unexpected expenses (emergency fund)
Reduce or pay off mortgage
College for child(ren)
Pay off credit cards
Help support aging parents
Mid-term (3–7 years)
Car
Furniture
Boat
Family vacation
Build retirement wealth
Buy a new home
Alternate income in case of death or disability
Build savings for unexpected expenses (emergency fund)
Reduce or pay off mortgage
College for child(ren)
Pay off credit cards
Help support aging parents
Long-term (7+ years)
Car
Furniture
Boat
Family vacation
Build retirement wealth
Buy a new home
Alternate income in case of death or disability
Build savings for unexpected expenses (emergency fund)
Reduce or pay off mortgage
College for child(ren)
Pay off credit cards
Help support aging parents
Of the goals discussed above, which is the most important to you?
What are you doing today to accomplish these goals?
How much do you believe you can comfortably set aside each month to achieve these goals?
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