CONFIDENTIAL FINANCIAL PROFILE
Full Name
Agent
Referred By
Walk In?
FILING STATUS
Married Filing Jointly Married Filing Separately Single Head of Household Qualifying Widow(er)
CLIENT INFORMATION
SSN
Date of Birth
Month Day Year
Date
Address
City
State
Zip Code
Marital Status
Phone Number
Phone Carrier
Email
Drivers License State
Drivers License #
Issue Date
Month Day Year
Date
Expiration Date
Month Day Year
Date
Employer
Title/Occupation
Date Employed
Month Day Year
Date
Company Address
City
State
Zip Code
SPOUSAL INFORMATION
Name
SSN
Date of Birth
Month Day Year
Date
City
State
Zip Code
Marital Status
Phone Number
Phone Carrier
Email
Driver's License State
example@example.com
Driver's License #
example@example.com
Issue Date
Month Day Year
Date
Expiration Date
Month Day Year
Date
Employer
Date Employed
Month Day Year
Date
Title/Occupation
Company Address
City
State
Zip Code
DEPENDENT INFORMATION (PLEASE LIST ALL DEPENDENTS)
Name
SSN
Date of Birth
Month Day Year
Date
Relationship
# Of Months Lived With You
Name
SSN
Date of Birth
Month Day Year
Date
Relationship
# Of Months Lived With You
Name
SSN
Date of Birth
Month Day Year
Date
Relationship
# Of Months Lived With You
Name
SSN
Date of Birth
Month Day Year
Date
Relationship
# Of Months Lived With You
DEPENDENT CARE INFORMATION
Dependent Care Name or Daycare Entity
EIN/SSN
Address
Address
Street Address Line 2
City State
Zip Code
HOBBIES & INTERESTS
Hobbies
Interests
FINANCIAL COUNSELING INFO (CHECK ALL THAT APPLY)
Do you owe Government
No Yes
Build Credit?
No Yes
Did you file all your prior year taxes
Yes No
Debt Elimination?
No Yes
Seeking Financial Advice?
Yes No
Life Insurance?
No Yes
New Home Purchase for 2013?
No Yes
Investments?
No Yes
Disability Income?
No Yes
401K?
No Yes
Car Purchase?
No Yes
TAX DEDUCTIONS INFORMATION
TOTAL INCOME
TAXES PAID
EDUCATION EXPENSES
Real Estate Taxes
Student Loan Interest
Personal property taxes
Post-Secondary Tuition/Fees
State Income Taxes
Any Other Job Training
MISCELLANEOUS EXPENSES
Employment/Job Seeking Expenses
Uniform purchase and cleaning
Work tools
Union dues
Office in Home expenses
Vehicle use mile
Miles to 2nd job
Business travel
Landscaping
Hobby Expense
Meals and Entertainment
Transportation
MEDICAL EXPENSES
Prescription Drugs
Medical Insurance
Dental Insurance
Long Term Care Insurance
Hospital and Emergency Bills
Lab and x-ray expenses
Visiting nurses/in-home care
Glasses and contact lenses
Hearing aids and batteries
Canes/Crutches/Braces
Wheel chairs
Depreciation
Other medical transportation
Other medical expenses
Self Employed Business Expenses
Legal and Professional Services
Advertising expenses
Car/Truck Expenses (Mileage)
Rent or Lease Payments
Office Expenses
Repairs and Maintenance
Supplies
Taxes and Licenses
Business Meals and Entertainment
Utilities/Telephone Expenses
Other miscellaneous expenses
CONTRIBUTIONS
Value of Furniture or clothes given
Church tithes and offerings
Goodwill/Salvation Army
Car's value- Donation
Others
VOLUNTEER WORK EXPENSES
Church, scouts, charitable organizations
Auto miles
Interest Paid
Home Mortgage interest
Points paid at closing
Closing Cost Paid
Investment Interest
Business Loan Interest
Car Loan Interest-Used for Bus.
CASUALTY LOSSES
Accident, fire, theft, disaster expenses.
EQUIPMENT PURCHASES/ CAPITAL IMPROVEMENTS
Description & New or Used
Purchase Date
Month Day Year
Date
Purchase Cost
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
Signature
Clear
Date
Month Day Year
Date
Should be Empty: