Client Assessment Form

This is the same form we hand out in class, just easier. It saves as you go on this device, so you can stop and come back. Fill in what you know and leave the rest blank — nothing here is a test.

Everything you enter goes straight to Jason and nowhere else. Take your time; there is no timer and nothing is shared.

Family profile

You first, then your spouse or partner if you have one.

Your first name

Your last name

Date of birth

Sex

Phone

Street address

City

State

ZIP

Spouse or partner

First name

Last name

Date of birth

Sex

Phone

Children

Name

Date of birth

Income

Gross means before tax. If you are already retired, put N/A for employer.

Your employer

Your position

Annual salary, gross

Bonus

Other income

Source of other income

Your estimated retirement age

Your Social Security at full retirement age, monthly

Spouse or partner

Employer

Position

Annual salary, gross

Bonus

Other income

Source

Estimated retirement age

Social Security at full retirement age, monthly

Total retirement income you would like, per month

This is the most important number on the whole form. What you would want to actually spend each month, after tax, in today's money.

Expected inflation

Expected tax bracket in retirement

Current monthly expenses

Property and mortgage

Primary residence

Type

Monthly payment

Current value

Mortgage balance

Rate

Other property

Type

Monthly payment

Current value

Mortgage balance

Rate

Qualified accounts

401(k), IRA, Roth, SEP, 403(b), TSP, ESOP and anything else with tax rules attached.

Type

Owner

Current balance

Annual contributions

Current assets

Checking, savings, CDs, brokerage, mutual funds, money market, stocks, bonds.

Type

Owner

Current balance

Annual contributions

Life insurance

If you have a policy but cannot find the details, put the company name and leave the rest blank.

Who is insured

Company

Type

Year bought

Face amount

Annual premium

Cash value

If term, how many years

Pensions and annuities

Company pensions, annuities, and any other benefit that pays you an income.

Owner

Provider

Annual benefit

Starts at age

Survivor benefit

Cost of living increase

Current liabilities

Auto loans, personal loans, college loans, credit cards. If you owe nothing, tick the box.

We are debt free

Owner

What is it

Balance

Monthly payment

Rate

Future cash needs

New car, a wedding, remodeling, a big trip — anything you know is coming.

What is it

Cost

At what age

Does it repeat

How often

What matters most

The most important financial goals you want to accomplish, in your own words, most important first. This is the part Jason reads twice.

Goal number one Goal number two Goal number three Anyone else involved in the decision — CPA, attorney, family? Anything else you want Jason to know before you meet

Send it

Your appointment date, if you know it

Time

The information above is mine and is accurate as far as I know. I understand Jason will use it to prepare for our meeting.

Nothing is sent until you press this button.

Retirement Of Your Dreams · Jason Bergquist, Certified Financial Fiduciary
Your information is never sold or shared.