Simple
Three Rules
Section Six:
Forms
Forms
Certificate of Completion
Client Profile
Diagnosis and Prescription
Financial Opinion Survey
Permission Agreement
Personal Asset and Debt Inventory
Personal Cash Flow Plan
Personal Financial Habit Assessment and Interpretation
Values Questionnaire
This certificate is awarded to
.
for successful completion of the
le
Simp
Three Rules
Financial Workshop
Instructor Signature Date of Completion
Client Profile
Name ______________________________________________________________
Address ______________________________________________________________
City _____________________________ State ___________ Zip _____________
Home Phone __________________________ Cell Phone ________________________
Email _________________________________ Fax ________________________
Kids Names and Ages ______________________________________________________
Work (his) _______________________________________ Phone_________________
Work (hers) _______________________________________ Phone_________________
Preliminary
1. Why are you here and how can I help?
When did the problems start?
What do you think caused the problem?
2. What do you hope to achieve as a result of this process?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If your financial situation was perfect, what would be different?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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What are your three primary financial goals?
________________________________________________________________________
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3. How badly do you want to accomplish these goals? Are you willing to do whatever it
takes? (If you don’t we’re wasting our time!)
4. 4D’s of Change
• Desire
• Decision
• Discipline
• Delight
Specifics
1. How often do you get paid?
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2. What happens to the paychecks?
________________________________________________________________________
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3. How many checking accounts and savings accounts do you have?
________________________________________________________________________
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4. Who pays the bills? When? How often?
________________________________________________________________________
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5. Did you have to pay additional taxes or did you get money back as a result of last year’s
tax return?
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6. How is your credit record?
________________________________________________________________________
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7. Are there any bills that are past due? Anything close to repossession or foreclosure?
________________________________________________________________________
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8. Are you current on your taxes?
________________________________________________________________________
________________________________________________________________________
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Diagnosis and Prescription
What financial goals have been discussed?
________________________________________________________________________
________________________________________________________________________
What financial problems, if any, did the financial physical reveal?
________________________________________________________________________
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What is the cause of the problems identified?
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What actions can be taken to eliminate these problems and accomplish the financial goals?
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Continue on reverse as needed.
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Financial Opinion Survey
Answer the following questions honestly based on your personal opinion.
1. In today’s world, a typical family needs ___ credit cards.
2. The best way to buy a car is to [ ] buy new [ ] buy used [ ] lease.
3. It’s OK to take out a loan to purchase a car. [ ] Yes [ ] No
4. It’s OK to buy furniture on payments. [ ] Yes [ ] No
5. It’s OK to borrow money to pay for vacations. [ ] Yes [ ] No
6. It’s OK to borrow money for a boat, RV or motocycle. [ ] Yes [ ] No
7. It’s better to buy a home than to rent. [ ] Yes [ ] No
8. A mortgage term of _____ years is normal and OK.
9. A family should save ___ percent of their income for future needs.
10. A family should give ___ percent of their income back to God.
11. Does it make sense to give when you are struggling to repay debt? [ ] Yes [ ] No
12. Living on a budget is important. [ ] Yes [ ] No
Answer the following only if married:
13. [ ] Husband [ ] Wife [ ] Either should assume primary responsibility for paying bills.
14. A household’s financial situation should be reviewed:
[ ] weekly, [ ] monthly, [ ] quarterly, [ ] annually.
15. It’s okay for husbands and wives to have separate bank accounts. [ ] Yes [ ] No
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Permission Agreement
I hereby give permission to __________________________ to share my financial
information with the deacons at _________________________________ Church.
Date _________________________
_____________________________
Signed
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PERSONAL ASSET AND DEBT INVENTORY www.ThreeRules.org
ASSETS: What we own DEBT: What we owe
Description Value Description Payment Rate Balance Owed
Car # 1 Car # 1 Loan
Car # 2 Car # 2 Loan
Real Estate Mortgage Loan
Boats Personal Loan
Motorcycles Personal Loan
RVs Personal Loan
Other Credit Card
Emergency Savings Credit Card
Short Term Savings Credit Card
CD's (GIC's) Credit Card
IRA, 401k (RRSP, RPP) Credit Card
Mutual Funds Credit Card
Stocks, Bonds, etc. Student Loans
Cash Value Life Ins Other
Other Other
Other Total Payments/Debts
Total Assets Net Worth -- Assets minus Debts
( ) equals Canadian equivalent
PERSONAL CASH FLOW PLAN www.ThreeRules.org
INCOME (PER MONTH)
INCOME 1
INCOME 2
INCOME 3
TOTAL INCOME
CATEGORY 1 EXPENSES (PER MONTH) CATEGORY 2 EXPENSES (PER MONTH) CATEGORY 3 EXPENSES (PER MONTH)
GIVING HOUSING PROPERTY TAXES *
CHURCH RENT (SEE CAT 1 FOR MORTGAGE) HOME INSURANCE *
OTHER PROPERTY TAXES HOME MAINTENANCE
TAXES INSURANCE CAR INSURANCE *
FEDERAL TAX UTILITIES (GAS, ELEC, WATER) CAR MAINTENANCE
SOCIAL SECURITY (US ONLY) GARBAGE PICK-UP CLOTHING/HIM
MEDICARE TELEPHONE/CELL PHONES CLOTHING/HER
STATE/PROVINCIAL TAX FOOD CLOTHING/KIDS
CITY TAX FOOD DOCTOR
DEBT RETIREMENT CAR DENTIST
CAR LOANS GAS EYE CARE
MORTGAGE LOAN INSURANCE (IF PAID MONTHLY) LIFE INSURANCE *
PERSONAL LOANS INSURANCE HEALTH INSURANCE *
CREDIT CARDS HEALTH (IF PAID MONTHLY) VACATION
STUDENT LOANS LIFE (IF PAID MONTHLY) GIFTS (BIRTHDAYS, ETC.)
OTHER LOANS ENTERTAINMENT GIFTS (CHRISTMAS)
SAVINGS ENTERTAINMENT OTHER
EMERGENCY ACCOUNT EATING OUT OTHER
SHORT TERM SAVINGS BABYSITTERS OTHER
LONG TERM SAVINGS CABLE/INTERNET
TUITION/CHILD CARE
TOTAL CATEGORY 1 EXPENSES TUITION TOTAL CATEGORY 3 EXPENSES
DAY CARE/CHILD SUPPORT * Leave blank if included in prior column.
MISCELLANEOUS
PRESCRIPTIONS
SUBSCRIPTIONS
Future Needs: LUNCHES
PET SUPPLIES/VET
HAIRCUTS, ETC TOTAL EXPENSE
CIGARETTES (Category 1+2+3)
MISC
MISC
MISC SURPLUS/DEFICIT
CASH (WALKING AROUND MONEY) (Total Income - Total Expense)
TOTAL CATEGORY 2 EXPENSES
CATEGORY 1 % OF INCOME CATEGORY 2 % OF INCOME CATEGORY 3 % OF INCOME
Personal Financial Habits Assessment
When you answer these questions, it is important that you do so 100% truthfully. If you do not
answer them truthfully, you are only kidding yourself.
1. Are you living on a budget? [ ] Yes [ ] No
2. Do you know how much debt you have within $1000? [ ] Yes [ ] No
3. Are you saving on a regular basis? [ ] Yes [ ] No
4. Do you balance your checkbook monthly? [ ] Yes [ ] No
5. Are you happy with your giving? [ ] Yes [ ] No
6. Do you pay off your entire credit card balance each month? [ ] Yes [ ] No
7. Do you make all your loan payments on time? [ ] Yes [ ] No
8. Do you know how much cash you spend every week? [ ] Yes [ ] No
9. Do you buy things on impulse? [ ] Yes [ ] No
10. Do you have more than one personal credit card? [ ] Yes [ ] No
11. Are you making payments on automobiles? [ ] Yes [ ] No
12. Are you making payments on a boat, RV or motorcycle? [ ] Yes [ ] No
13. Do you owe money to relatives? [ ] Yes [ ] No
14. Do you ever get a cash advance on a credit card? [ ] Yes [ ] No
15. Have you ever taken a cash advance against your paycheck? [ ] Yes [ ] No
16. Do you ever use your credit card because you can’t afford to pay cash? [ ] Yes [ ] No
Personal Financal Habit Assessment Results
If you answered “Yes” to questions 1-8 and “No” to the rest, you have a perfect score of 100%.
Congratulations!
If you answered “No” to any of Questions 1-8, that is an area that will need some work.
If you answered “Yes” to any of questions 9-16, that is also an area that needs
some work.
2nd Edition
Revised 8/04
Values Questionnaire
1. Husband [ ] Wife [ ] should assume primary responsibility for paying our bills.
2. We should plan to save ____% of our income for future needs.
3. We need ___ credit cards.
4. We should [ ] buy new cars [ ] buy used cars [ ] lease our cars.
5. It’s OK to take out a loan to purchase a car. [ ] Yes [ ] No
6. It’s OK to buy furniture on payments. [ ] Yes [ ] No
7. It’s OK to borrow money to pay for vacations. [ ] Yes [ ] No
8. It’s better to buy a home than to rent. [ ] Yes [ ] No
9. We should mortgage our home for ___ years.
10. We should plan to give ___ % of our income back to God.
11. We should live on a budget. [ ] Yes [ ] No
12. We should own everything in common. [ ] Yes [ ] No
13. We should review our financial situation
[ ] weekly [ ] monthly, [ ] quarterly, [ ] annually.
14. We should discuss any unbudgeted purchase over $__________.
15. We should pray about any purchase over $__________.
16. We should live on one income after we have children. [ ] Yes [ ] No
17. We should send our children to Christian School. [ ] Yes [ ] No
18. We should agree to agree on all of the above. [ ] Yes [ ] No
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