Step 1 of 9 11% Confidentiality: As your personal financial coach, we know your financial information is private, and you can be assured that we employ every reasonable data security measure available – including computer hardware locks, physical locks on file cabinets, network password protections, hard and soft network firewalls, and 128 bit data encryption. Your files, electronic and otherwise, are available only to our firm staff. Your electronic files are backed up daily and stored on private, offsite storage media with high-level password protection. We retain copies of the documents necessary for the performance of our services and those which are required by law. The personal, non-public information we collect from you has been derived from the following sources: Pre-coaching questionnaires, pre-coaching worksheet exercises, file notes from coaching sessions, direct correspondence from you and any other data or documents that you may have provided for use during your coaching sessions. Information we receive from creditors and/or your personal vendors as you may specifically retain our firm to represent you as an agent to these parties. The information you give us about your personal or business records is reserved only for our staff or agents who need to know this information in order to properly service your account. No personal information will ever be disclosed about you to anyone, except that which is already public, required by law, or required to properly service your account. We will not make any disclosure of your private financial information without your prior consent. Should you close your account with us or become an inactive client, we will continue to adhere to this policy as written here. We are committed to retaining your confidence, and want to assure you that any information you give us remains safe and confidential. By continuing to complete this form you agree to the terms and conditions above.Agreement* I agree Personal InformationName* First Last Age*Spouse first Name AgeAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone 1*Cell Phone 2Email Address 1* Email Address 2 Number of Dependants*1st Dependant Name First 1st Dependant AgePlease enter a number less than or equal to 100.2nd Dependant Name First 2nd Dependant AgePlease enter a number less than or equal to 100.3rd Dependant Name First 3rd Dependant AgePlease enter a number less than or equal to 100.4th Dependant Name First 4th Dependant AgePlease enter a number less than or equal to 100.5th Dependant Name First 5th Dependant AgePlease enter a number less than or equal to 100.6th Dependant Name First 6th Dependant AgePlease enter a number less than or equal to 100.Church Affiliation Last Year's Combined Household Income:* IncomeNumber of Household Incomes (Please enter up to two incomes)*Please enter a number less than or equal to 2.Employer 1* Employment Type* Part Time Full Time Job Description* Length of Current Employment in Years* Work PhoneThis Job's Total Annual Income*Bonus / Commission AmountFrequency Monthly Quarterly Annually This Jobs Average Monthly Take Home Pay*Employer 2* Employment Type* Part Time Full Time Job Description* Length of Current Employment in Years* Work PhoneThis Job's Total Annual Income*Bonus / Commission AmountFrequency Monthly Quarterly Annually This Jobs Average Monthly Take Home Pay* Breakdown of DebtCheck all That Apply Credit Cards Car Loans Personal Loans Student Loans Tax Debt Other Number of Credit CardsCredit Card Payoff Balance TotalAre You Current? Yes No Number of Car LoansCar Loans Payoff Balance TotalAre You Current? Yes No Number of Personal LoansPersonal Loans Payoff BalanceAre You Current? Yes No Number of Student LoansStudent Loans Payoff BalanceAre You Current? Yes No Tax Debt Type (eg IRS 2015, Property Taxes, etc…) Total Tax Debt AmountAre You Current? Yes No Other Loan Other Loan Payoff Balance MortgageFair Market value of HomeCurrent Loan Term in Years (eg 15, 30)Loan Type ARM Fixed 1st Mortgage Interest Rate %1st Mortgage Payoff BalanceAre You Current? Yes No 2nd Mortgage Interest Rate %2nd Mortgage Payoff BalanceAre You Current? Yes No Total Rent/Mortgage including EscrowTotal Household expenses per month (What it takes to live excluding housing cost and debt payments)Total Debt Payments Per Month (excluding housing) Breakdown of Cash SavingsEmergency FundsAnnual Expense Funds (Self-Escrow)All Other Cash Savings (not including retirement accounts)Total Cash Savings Non-Liquid AssetsCurrently Contributing to Retirement?* Yes No Total Retirement Savings Balances (401k/403b/IRA/etc...)Other Savings Type 1 (College 529, Pension, Roth IRA) Other Savings Type 1 AmountOther Savings Type 2 (College 529, Pension, Roth IRA) Other Savings Type 2 Amount Coaching Priority Analysis Identify your top 3 priorities for the next 6 months with "1", "2" or "3".Cash Flow Planning / Develop a BudgetPlease enter a number less than or equal to 3.Debt Elimination or Assist With CreditorsPlease enter a number less than or equal to 3.Establish An Emergency/Opportunity Savings FundPlease enter a number less than or equal to 3.Retirement Planning / Investment PlanningPlease enter a number less than or equal to 3.Purchasing A HomePlease enter a number less than or equal to 3.Small Business PlanningPlease enter a number less than or equal to 3.College Planning for Children / GrandchildrenPlease enter a number less than or equal to 3.Tax Planning / Insurance ReviewPlease enter a number less than or equal to 3.Other GoalsPlease enter a number less than or equal to 3.Please Specify How Did You Hear About Storehouse Financial?Please check all that apply Dave Ramsey Website Storehouse Financial Website Google Personal Referral Church Referral Financial Peace University Class Dave Ramsey Headquarters referral Business Referral Radio Spot Seminar Other Specify Personal Referral Specify Church Referral Specify Peace University Class Location Specify Business Referral Specify Radio Station Specify Seminar Location and Approximate Date Other
