Financial Health Assessment

The SMART Lifestyle Financial Health Assessment

* Indicates required field

Personal Information

Name *

First

Last

Spouse Name *

First

Last

Marital Status *

Single Married Divorced Widowed

Birth Date *

Spouse Birth Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Spouse Email *

Spouse Phone Number *

Goals

Please rank 1 through 5 on each below, 1 being of most importance and 5 being of least importance.

I want to make sure my money lasts throughout my lifetime *

I would like to ensure that my assets are protected from losses *

I would like to pay less in taxes *

I want to pass on as much as possible to children/heirs *

I would like to protect myself and my family from catastrophic long-term care costs *

Document Checklist

Will *

Financial Power of Attorney *

Medical Power of Attorney *

Living Trust *

Retirement Plan

Planned Retirement Age *

Cash Flow

Income Types

Social Security *

Pension *

Wages *

Other Income *

Planned Retirement Age (Spouse) *

Cash Flow

Income Types

Social Security *

Pension *

Wages *

Other Income *

Approximate Annual Income (+) *

Approximate Annual Expenses (-) *

Approximate Living Income (=) *

Future Income
(Go to www.ssa.gov to get your latest social security statement)

You

Spouse

Social Security PIA *

Anticipated Age to Draw *

Social Security PIA *

Anticipated Age to Draw *

Future Pension Amount *

Anticipated Age to Draw *

Future Pension Amount *

Anticipated Age to Draw *

Current Insurance (Excluding employer-covered insurance)

Life Insurance - insured, face amount, premium, type (term/whole?) *

Medicare Supplement - insured, plan type, premium *

Do you have Long Term Care Insurance? *

Do you have any health concerns? If so, please list them below. *

Mortgage

Primary Residence *

Owned Rented

Approximate Value *

Amount Owed *

Secondary Residence *

Owned Rented

Approximate Value *

Amount Owed *

Assets

Taxable Accounts

Checking *

Savings / Money Market *

CD *

Total *

Tax Deferred Accounts

401k *

403b *

IRA *

Total *

Tax Free Accounts

Roth IRA *

Indexed Universal Life (IUL) *

Total *

Submit