FREE EQ Express-Retirement Financial Check-up

CONFIDENTIAL PERSONAL PROFILE
for your Free EQ Professional Financial Check-up
Please submit this form for a free, professional & confidential no-obligation evaluation
All fields with a red star (*) are required - the other fields are recommended, but optional.

*First Name:

*Last Name:

*E-mail address:

Tel #

Mailing address:

State:

City:

*ZIP:

*Through Equidigm,
this is a:

First request, or
Update to a previous check-up

*Last financial check-up done by an expert?

* How would you like your report back:
(select all that apply)

Email	Same as above or:
Phone	Same as above or:
Snail mail	Same address as above or:
By hand	Same address as above or:

* Your date of birth:

Marital status:

Single Married Widow Divorced/Separated

Spouse's firstname :

Spouse's DOB:

Children?

Boy(s) Girl(s)

Age of children:

Financial situation

* Existing home value:

* Interest rate:

* Monthly payment
(Capital & Interest)

* Term, in years:

years

* Original Mortgage Amount:

* Current Mortgage Balance:

Your mortgage is with:
(name of lender)

Years left to pay on your mortgage:

years

* Credit cards debts:

Total $
Monthly: $

* Car loan(s) balance:

Total $
Monthly: $

* Other debts to be paid off:

Total: $
Monthly: $

If money was available for other than paying debts, which amount would you like/need?

Do you have life insurance on yourself?

Yes No

Total Amount of your insurance coverage:

Does your spouse has life insurance?

Yes No

Total Amount of his/her insurance coverage:

Do you have any type of retirement plan?

401k IRA Other

Total present value of retirement funds :

Do you own any investment assets?

Mutual funds	$	Stock/Bonds	$
Real estate	$	Other	$

In how many years would you like to retire?

Monthly income desired at retirement:

Your credit score (FICO), if known

In need of credit help?
(re. Financial Counselor)

Yes No Maybe

General Financial Status

Element

Presently

Desired

Cash flow
(The difference between what your earn and what you spend)

Very bad	Bad	OK	Very good	Excellent

Very bad	Bad	OK	Very good	Excellent

Level of debts
(including mortgage, credit cards, vehicles, loans, etc.)

Very high	High	OK	Very low	No debt

Very high	High	OK	Very low	No debt

Financial protection for your family
if you were to pass away, will your family be protected financially?)

None	Some	OK	High	Very high

None	Some	OK	High	Very high

Level of financial stress
(Do you feel pressured by the debts you have?)

Very high	High	OK	Very low	No stress

Very high	High	OK	Very low	No stress

Emergency Funds
(In case of emergency, do you have access to immediate funds)

None	Some	OK	High	Very High

None	Some	OK	High	Very High

Long-term Savings
(Long-term savings allowing for the retirement you wish for)

None	Some	OK	High	Very High

None	Some	OK	High	Very High

Funds for kids' Education
(if your child(ren) is/are of age)

None	Some	OK	High	For any college

None	Some	OK	High	For any college

Estate Planning
How ready are you for retirement and inheritance to leave behind you?

None	Some	OK	High	100%

None	Some	OK	High	100%

Risk taking
How do you see yourself when it comes to taking financial risks?

None	Little risk	Avge	High	Maximum

None	Little risk	Avge	High	Maximum

Credit rating
How do you rate your credit?

Poor	Not great	Avge	High	Perfect

Poor	Not great	Avge	High	Perfect

Please select the financial services you might need help with, or for which you would like more information:

(Select all that applies)

Home Loans
	Home purchase
	Refinancing
	Home improvements
	Mortgage acceleration
	Investment Property
	Debt Consolidation
	Other

Insurance
	Life
	Mortgage
	Disability
	Long Term Disability
	Automobile
	Exchange policies
	Other

Investment
	Education Fund
	Retirement Planning
	Mutual Funds
	Tax Deferred Plans
	IRA Plans
	Emergency Fund
	Other

Living Trust Other type of Trusts Life Settlements for Elderly

* Who referred you to EQ or this webpage?

Comments/Questions:

All submitted information is strictly confidential, for the purpose of preparing a professional,
no obligation financial checkup evaluation. An annual check-up is recommended to ensure your finances are in order and generating the results you are expecting and/or hoping for.