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NHU FINANCIAL INTAKE FORM:

PERSONAL INFORMATION:

First Name *

Last Name *

Email *

Phone *

City *

State *

Sex

M

F

Date of birth *

Desired Retirement Age *

Spouse Name *

Spouse's Email *

Spouse's Phone *

Spouse's Address *

Spouse's Sex

M

F

Spouse's Date Of Birth

Spouse's Desired Retirement Age *

Number of children *

Age of Children *

State of Issue *

CURRENT CONCERNS:

Other:

What are your Future Expenditures?

REAL ESTATE:

Please answer accordingly.

Mortgage Payment (Principal & Interest only) $ *

Term Remaining (years) *

Interest rate (%) *

Outstanding Mortgage $ *

Type of Mortgage (check one and indicate applicable term below) *

Fixed term (30 years, 15 years, etc.)

ARM (5 yr, 7 yr, 10 yr)

Interest Only

Indicate applicable term in "other" section

Other

Other Mortgage Payment (Principal & Interest only) $

Term Remaining (years)

Outstanding Mortgage $

Interest rate (%)

Type of Mortgage (check one and indicate applicable term below)

Fixed term (30 years, 15 years, etc.)

ARM (5 yr, 7 yr, 10 yr)

Interest Only

Indicate applicable term in "other" section

Other

Please list any outstanding debts other than mortgages.

Item 1

Name
Amount Owed ($)
Interest Rate (%)
Minimum Payment ($)
Actual Payment ($)

Item 2

Name
Amount Owed ($)
Interest Rate (%)
Minimum Payment ($)
Actual Payment ($)

Item 3

Name
Amount Owed ($)
Interest Rate (%)
Minimum Payment ($)
Actual Payment ($)

Other Outstanding Debts

INSURANCE:

Please answer accordingly.

Life Insurance - Wife

Yes

No

Monthly Premium, Death Benefit, Cash Value

Life Insurance - Husband

Yes

No

Monthly Premium, Death Benefit, Cash Value

INCOME AND EXPENSES:

Please answer accordingly.

Monthly Gross Income (Husband)

Monthly Gross Income (Wife)

Social Security (Husband)

Social Security (Wife)

Pension (Husband)

Pension (Wife)

Investment Income (Husband)

Investment Income (Wife)

Rental Income (Husband)

Rental Income (Wife)

Other Income (Husband)

Other Income (Wife)

Desired Retirement Income $ (Husband)

Desired Retirement Income $ (Wife)

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

Yes

No

Maybe

If yes or maybe, please explain

Required Documents - Tax Return or Current Pay Stub *

Please upload your most recent tax return.

Required Documents - Additional statements *

Please upload your most recent 401 statements, bank statements, investment statements.

REDIRECTED MONEY

Please answer accordingly.

Monthly over-payments from debt

Monthly contributions to investments

Spending Planner (found discretionary money)

Amount to pull from qualified accounts (5% or 10% a year or 72T)

Amount to pull from Non qualified accounts

Life insurance Premium being replaced monthly

Other available money (future)

TOTAL $

$

Producer's thoughts on case *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Call: 301-509-7138

Email: [email protected]