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Retire 10 Years Earlier Intake Sheet
Fill out form below and hit the submit button,
'Your Current Household Debt/Income/Excess/Cash Flow Snapshot'
Full Name -
Phone -
Address -
Email -
MORTGAGES
Fill in what you know. Approximates are fine.
Lender Name
Mortgage Start Date
Mortgage Term
Monthly Payments*
Extra
Principle Payments
Interest
Rate
Escrow Payment
Mortgage Insurance Payment
Current
Mortgage Balance
Original Mortgage Amount
*Including Principle, Interest, Escrow, PMI/Mortgage Insurance, etc.
LOANS
Fill in what you know. Approximates are fine.
Account
Name*
Loan Start
Date
Loan
Term
Monthly Payment
Extra
Principle Payment
Interest
Rate
Current Loan
Balance
Original Loan
Amount
*Auto Loans, Student Loans, Personal Loans, Business Loans, etc.
REVOLVING CREDIT/CREDIT CARDS, ETC.
Fill in what you know. Approximates are fine.
Type of
Credit*
Current
Balance
Minimum
Payment
Extra
Principle Payment
Interest
Rate
Credit
Limit
*LOC - Line of Credit, Credit Card, HELOC - Home Equity Line of Credit
AVERAGE HOUSEHOLD NET INCOME (TAKE HOME PAY)
Income Source
Payment Frequency*
Average Net Income
Per Paycheck
*Every Week, Every Other Week, Once a Month, Twice a Month, Every Three Months, Twice a Year, Once a Year.
Monthly Expenses (All Bills--Food, Gas, Electricity, Internet, etc.)
AND
Monthly Discretionary Income (EXCE$$ - Left after Bills & Debts are paid)
Addtl'
Info
You
State of
Residence
Age
Date of
Birth
Nicotine
Usage?
Good Health?
Yes/No?
Any Frequent
Prescription Usage?
Do You Have
401K's? IRA's?
Spouse
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