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Debt Report Data Form

Agent Name

Agent Phone

Agent Email Address

M

F

Your Name

Birth Date

Desired Retirement Age

M

F

Spouse Name

Birth Date

Desired Retirement Age

Number of Children

Child #1 Age

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Child #2 Age

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Child #3 Age

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Child #4 Age

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Child #5 Age

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Current Concerns

Future Expenditures*

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Real Estate

Personal Residence Information:

Mortgage Payment (P&I only)*

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Outstanding Mortage*

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Term Remaining (years)*

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Interest*

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Other Property Owned:

Mortgage Payment (P&I only)

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Outstanding Mortage

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Term Remaining (years)

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Interest

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Debt Related

Please list any Outstanding Debt other than mortgages*

(Name - Amount Owed - Interest Rate - Minimum Payment - Actual Payment)

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Insurance

Husband Life Insurance

General Health:*

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Checkbox Options Title*

Preferred

Standard Non-Tobacco

Tobacco

Permanent or Term

Premium*

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Death Benefit*

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Cash Value*

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Wife Life Insurance

General Health:*

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Checkbox Options Title*

Preferred

Standard Non-Tobacco

Tobacco

Permanent or Term

Premium*

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Death Benefit*

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Cash Value*

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Income & Expenses

Monthly Gross Income Husband

Wages/Salary*

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Social Secutiry*

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Pension*

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Investment Income*

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Rental Income*

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Other Income*

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Total Income*

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Desired Retirement Income*

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Monthly Gross Income Wife

Wages/Salary*

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Social Secutiry*

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Pension*

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Investment Income*

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Rental Income*

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Other Income*

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Total Income*

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Desired Retirement Income*

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Do you expect a significant change in cash flow in the near future?*

Yes

No

If yes, please explain.*

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Investment Accounts: Non-Qualified Accounts, Qualified Accounts, Savings Accounts

List account type IRA, Roth, 401k, 403b, 457, Savings, etc.

For all accounts please list the Financial Institution, The Account Type, The Account Value, The Monthly Contribution and if the Account Value and Monthly Contribution are Available.

Account 1*

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Account 2

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Account 3

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Account 4

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Account 5

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Please list any assets you have not previously included:*

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Debt Report Data Form

Current Concerns

Real Estate

Personal Residence Information:

Other Property Owned:

Debt Related

Insurance

Husband Life Insurance

Permanent or Term

Wife Life Insurance

Permanent or Term

Income & Expenses

Monthly Gross Income Husband

Monthly Gross Income Wife

Investment Accounts: Non-Qualified Accounts, Qualified Accounts, Savings Accounts

List account type IRA, Roth, 401k, 403b, 457, Savings, etc.

For all accounts please list the Financial Institution, The Account Type, The Account Value, The Monthly Contribution and if the Account Value and Monthly Contribution are Available.

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