Modern Financial Services Company

📋 Contact Information

Street Address

👪 Family & Household

Marital Status — Select one — Married Divorced Widowed Single Separated Domestic Partner Children — Names and Ages Other Dependents (elderly parents, disabled adults, etc.)

💰 Naked Numbers — Your Financial Reality

These questions help us understand where you truly stand. Be honest — this is your safe space.

Who else depends on your income that doesn't live with you? Do you count bonuses or side income in your monthly budget? — Select — Yes No What spending category would shock us if we checked your statements? What subscriptions do you still pay for but mentally canceled? How much do you spend monthly on things you forget 6 months later? Do you track your spending — or just guess? — Select — Track closely Mostly guess Which debt stresses you the most — and why? Have you stopped opening statements for any account? — Select — Yes No Do you pay one debt with another (even mentally)? — Select — Yes No If everything collapsed, what could you sell in 72 hours? Do you know your retirement withdrawal penalties? — Select — Yes No / Not sure How much of your wealth is trapped in non-cash assets? How often do you carry more than 50% of your credit limit? — Select — Never Sometimes Often Always Have you opened credit to feel safer, not because you needed it? — Select — Yes No Are there accounts on your credit report you forgot or don't recognize? — Select — Yes No

🛡️ Insurance & Protection

Do you have any life insurance policies? — Select — Yes No If your income vanished for 6 months, what would protect you? Have you read your insurance policy in full? — Select — Yes No Would your household survive financially if you died tomorrow? — Select — Yes No Unsure Who pays the bills if you're injured — not emotionally, but financially?

📄 Existing Estate Documents

Where is the original Will located? Where is the Trust document?

🎁 Beneficiaries & Specific Bequests

Life Insurance — primary and contingent beneficiaries Retirement Accounts (401k, IRA) — beneficiaries Specific items you want to go to specific people

👥 Guardians, Executors & Trustees

Do you have minor children (under 18)? — Select — Yes No Backup Guardian

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Backup Executor

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Backup Trustee

🕊️ Funeral & Final Wishes

Preference — Select — Burial Cremation Undecided / No preference Cemetery or final resting place (if known) Specific instructions (service type, readings, music, etc.) Do you have prepaid funeral arrangements? — Select — Yes No

🌟 Your Financial Vision

What does financial freedom look like to you? List 3 priorities for the next 12 months One behavior to shift in the next 30 days What support or guidance do you need next?

🧠 Emotional & Hidden

What emotion makes you spend the most? How does your money behavior change when you feel powerless? What behavior would you be embarrassed for your kids to copy? Are there any hidden accounts, assets, or debts? Have you ever lied on a financial aid, tax, or insurance form? — Select — Yes No What part of your money life would you try to explain away?

📝 Additional Notes

Anything else we should know about your financial or estate planning goals?