Financial Lifestyle Analysis

Personal Details


Select A Representative *
Client Name *
Telephone *
Address *
Email *
Company
Marital Status *
Child(ren) Name(s) & Age

Goals & Dreams


If you could achieve your top five financial goals, what would they be?	Make a major purchase (car, furniture, boat, family vacation) Buy a home Pay off all credit cards Reduce or pay off your mortgage loan Build savings for unexpected expenses (auto repairs, medical bills, etc) Help support aging parents Find an alternative income source in case of death or illness Finance post-secondary education for your child(ren) Build retirement wealth Reduce taxes on inheritence for your child(ren)
Other Financial Goals
How much extra cash flow do you need every month? $
I want to reduce my taxes	Yes No
I want to plan my retirement	Yes No
I want to review my investments	Yes No
I want to save for further education	Yes No
I want to review my will or estate	Yes No
I want Insurance Planning (Life, Disability)	Yes No
Do you have a Business Plan and agreements?	Yes No

Debt Solutions Savings Chart


Mortgage Total Outstanding Balance $
Mortgage Payments	Weekly Bi-Weekly Monthly
Credit Cards Total Outstanding Balance $
Credit Cards Interest Rate %
Credit Cards Payments	Weekly Bi-Weekly Monthly
Auto Loans Total Outstanding Balance $
Auto Loans Payments	Weekly Bi-Weekly Monthly
Other Loans Total Outstanding Balance $
Other Loans Payments	Weekly Bi-Weekly Monthly

Cash Flow Solutions


I want to	Manage Expenses Make More Money
Occupation
Monthly Take Home Pay $
Monthly Rent $

Emergency Fund Solutions

Goal: Three Months of Income
Do you have an Emergency Fund?	Yes No
If Yes, How much? $

Protection Solutions

Goal: Protect your income from critical illness, disability, death & taxation
Critical Insurance Amount $
Disability Insurance Amount $
Life Insurance Amount $
Asset Amount $

Long-Term Savings Solutions

Goal: Build solid wealth reserves for retirement or any long term financial objective
Current Savings $
How much can you save monthly? $
RRSP Value $
House Value $
Pension Plan $
Planned Retirement Age
RRSP contribution room

Exit Strategy Solutions


Would you like a Tax-free Retirement Strategy	Yes No
Charitable giving for tax credits	Yes
Do you have a will?	Yes No

Permission to Proceed


*	I hereby authorize my Solutions 21 Financial representative to review the information provided in this form.