questionnaire - Tyrus Design. Small Business Web Design by xiuliliaofz

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									                                                              Savings Coach Questionnaire
Complete questionnaire and email back to savingscoach@gmail.com,
a representative will contact you to receive payment and clarify answers if necessary.
You can set up your first scheduled time slot if you are getting the 12 month Coaching Program.
Please allow up to 7 days for a coach to complete your Playbook and email back to you."
Fill in the blue boxes
Yellow boxes calculate automatically

Personal                                                      place x in appropriate box
           Email address
           Telephone#
           Age
           Sex                                         Male                      Female
           State
           Zip Code
           Student                                Full Time                    Part Time
           Marrital Status                           Single                      Married
           Profession
Net Worth
Assets                                                          Current       Invest to
Liquid Assets                                                   Balance        Monthly
          Checking (monthly average)                                   $0             $0
          Savings                                                      $0             $0
          Cash (tucked Away)                                           $0             $0

           Brokerage Accounts
                        Stocks                                          $0            $0
                        Bonds                                           $0            $0
                        Mutual Funds                                    $0            $0
                                                                        $0            $0 Total Brokerage Accounts
                                                                        $0            $0 Total Liquid Assets

Retirement Accounts
         401k/403b                                                      $0            $0            0%
                          Company match                                 0%            $0         $0.00 on the dollar
           Company Stock Purchase Plan                                  $0            $0
           IRA                                                          $0            $0
           MIP                                                          $0            $0
           Service Credit                                               $0            $0
                                                                        $0            $0 Total Retirement Accounts
                                                                        $0            $0 Total Investible Assets

Fair Market Value
          House                                                         $0
          Car                                                           $0
          Car                                                           $0
          Personal Property (jewelry, electronics…)                     $0
          Other Assets (specify)                                        $0
          Investments in Closely Held Business                          $0
          Investments in Real Estate                                    $0
                                                                        $0 Total Non-Current Assets
                                                                        $0 Total Assets

Savings Coach Questionnaire (cont.)
Liabilities                                                     Current       Minimum       Interest      Credit
Installment Loans                                               Balance         Due           Rate        Limit
            House Mortgage                                             $0           $0           0.00%
            2nd Mortgage                                               $0           $0           0.00%         $0
            Car Loan                                                   $0           $0           0.00%
            Car Lease                                                  $0           $0           0.00%
            Student Loan                                               $0           $0           0.00%
            Personal Loan                                              $0           $0           0.00%
         Other                                 $0             $0          0.00%
         Total                                 $0             $0

                                        Current      Minimum          Interest       Credit
Revolving Debt                          Balance        Due              Rate         Limit
          Credit Card 1                        $0          $0               0.0%           $0
          Credit Card 2                        $0          $0               0.0%           $0
          Credit Card 3                        $0          $0               0.0%           $0
          Credit Card 4                        $0          $0               0.0%           $0
          Credit Card 5                        $0          $0               0.0%           $0
          Credit Card 6                        $0          $0               0.0%           $0
          Credit Card 7                        $0          $0               0.0%           $0
          Credit Card 8                        $0          $0               0.0%           $0
          Credit Card 9                        $0          $0               0.0%           $0
          Credit Card 10                       $0          $0               0.0%           $0
          Department Store Card 1              $0          $0               0.0%           $0
          Department Store Card 2              $0          $0               0.0%           $0
          Department Store Card 3              $0          $0               0.0%           $0
          Department Store Card 4              $0          $0               0.0%           $0
          Department Store Card 5              $0          $0               0.0%           $0
          Department Store Card 6              $0          $0               0.0%           $0
          Department Store Card 7              $0          $0               0.0%           $0
          Department Store Card 8              $0          $0               0.0%           $0
          Department Store Card 9              $0          $0               0.0%           $0
          Department Store Card 10             $0          $0               0.0%           $0
          Total                                $0          $0                              $0

         Collection Account 1                  $0
         Collection Account 2                  $0
         Collection Account 3                  $0
                                               $0                Total Collections
                                               $0             $0 Total Liabilities

         FICO Credit Score                      0

Savings Coach Questionnaire (cont.)
Income (create drop down boxes)       Annual        Monthly        Biweekly        Weekly       Annually        Monthly
         Gross Salary                          $0             $0              $0       $0                  $0             $0
         Commissions/OT                        $0             $0              $0       $0                  $0             $0
                                                                              Gross Pay                    $0             $0
                                                    assume FICA tax withholding of 7.5%                    $0             $0
                                         assume average Fed Tax rate withholding of 9.5%                   $0             $0
                                          assume average State tax rate withholding of 2%                  $0             $0
                                                                   Total Tax #DIV/0!                       $0             $0
                                                                                  Net Pay                  $0             $0


         Yearly Bonus                          $0             $0             $0          $0                $0             $0
         2nd Job Income                        $0             $0             $0          $0                $0             $0
         Gifts                                 $0             $0             $0          $0                $0             $0
         Scholarship/Student Loans             $0             $0             $0          $0                $0             $0
         Family Aid                            $0             $0             $0          $0                $0             $0
         Interest/Dividends                    $0             $0             $0          $0                $0             $0
         Allimony                              $0             $0             $0          $0                $0             $0
         Child Support                         $0             $0             $0          $0                $0             $0
         Rental Income                         $0             $0             $0          $0                $0             $0
         Other Income                          $0             $0             $0          $0                $0             $0
                                                                         Total Other Income                $0             $0
                                                                         Total Gross Income                $0             $0
                                                                           Total Net Income                $0             $0
         Tax Return                            $0


Savings Coach Questionnaire (cont.)
Bills                                 Annual        Monthly        Annually        Monthly
           Rent                                              $0              $0              $0             $0
           Cell Phone                                        $0              $0              $0             $0
           Local Phone                                       $0              $0              $0             $0
           Cable TV                                          $0              $0              $0             $0
           Internet                                          $0              $0              $0             $0
           Electricity                                       $0              $0              $0             $0
           Water/Gas                                         $0              $0              $0             $0
           Car Insurance                                     $0              $0              $0             $0
           Health/Dental/Other Insurance                     $0              $0              $0             $0
           Life Insurance                                    $0              $0              $0             $0
           Union Dues                                        $0              $0              $0             $0
           Other                                             $0              $0              $0             $0
           Total                                                                             $0             $0

Expenses
           Do you track your expenses daily?                 Yes                             No

                                                    Annual         Monthly        Annually        Monthly
           Auto Fuel                                          $0             $0              $0             $0
           Auto Service                                       $0             $0              $0             $0   3 Largest Items to Review
           Bank Charges                                       $0             $0              $0             $0
           Charity                                            $0             $0              $0             $0
           Clothing                                           $0             $0              $0             $0
           Education (tuition/books)                          $0             $0              $0             $0
           Entertainment                                      $0             $0              $0             $0
           Food                                               $0             $0              $0             $0
                           Dining                             $0             $0              $0             $0
                           Fast Food                          $0             $0              $0             $0
                           Groceries                          $0             $0              $0             $0
           Gifts Given                                        $0             $0              $0             $0
           Health/Fitness                                     $0             $0              $0             $0
           Household Items                                    $0             $0              $0             $0
           Medical                                            $0             $0              $0             $0
                           Doctor visits                      $0             $0              $0             $0
                           Medicine                           $0             $0              $0             $0
           Personal Care                                      $0             $0              $0             $0
           Recreation                                         $0             $0              $0             $0
           Subscriptions                                      $0             $0              $0             $0
           Vacation/Travel                                    $0             $0              $0             $0
           Beer, tobacco, pharmaceuticals, gaming             $0             $0              $0             $0
           Other (specify)                                    $0             $0              $0             $0
           Other (specify)                                    $0             $0              $0             $0
           Other (specify)                                    $0             $0              $0             $0
           Misc. (% of net income)                           10%             $0              $0             $0
           Total                                                                             $0             $0

Do you have these insurances?
                        Medical Insurance                    Yes                             No
                        Dental Insurance                     Yes                             No
                        Life Insurance                       Yes                             No
                        Disability Insurance                 Yes                             No
                        Auto Insurance                       Yes                             No
                        Renters Insurance                    Yes                             No

								
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