Assessment Form

Please fill out the following form for a personal assessment.

TELL US ABOUT YOUR YOURSELF
First Name:
Last Name:
Email Address:
Phone Number (include area code):
How would you like to be contacted?	Email Phone
When would you like to be contacted?	Day Evening

 

TELL US ABOUT YOUR EXPENSES
Housing Expenses	Monthly Payment
First Mortgage	$
Second Mortgage	$
Property Taxes	$
House Insurance	$
Rent/Condo Fees	$
Telephone/Cell	$
Hydro	$
Heat	$
Water/Sewer	$
Cable/Satellite	$
Total Housing Expenses:	$
Living Expenses
Food	$
Child/Spousal Support	$
Childcare	$
Car/Lease Payment	$
Transportation Costs	$
Car Insurance	$
Life Insurance	$
Clothing	$
Medical/Dental	$
Laundry/Dry Cleaning	$
Pets	$
Bank Charges	$
Total Living Expenses:	$
Personal Expenses
Entertainment/Recreation	$
Grooming/Hairdresser	$
Magazine/Newspapers	$
Gifts/Donations	$
Total Personal Expenses:	$
Total Monthly Expenses:	$

 

TELL US ABOUT YOUR DEBT
Personal Debts	Total Owing	Monthly Payment
Car Loan 1	$	$
Car Loan 2	$	$
Bank Loan 1	$	$
Bank Loan 2	$	$
Line of Credit 1	$	$
Line of Credit 2	$	$
Overdraft 1	$	$
Overdraft 2	$	$
Student Loan 1	$	$
Student Loan 2	$	$
Finance Company 1	$	$
Finance Company 2	$	$
Credit Card 1	$	$
Credit Card 2	$	$
Credit Card 3	$	$
Credit Card 4	$	$
Payday Loan 1	$	$
Payday Loan 2	$	$
Payday Loan 3	$	$
Payday Loan 4	$	$
More Debts? List them below:
	$	$
	$	$
	$	$
	$	$
	$	$
Debt Totals:	$	$

 

TELL US ABOUT YOUR INCOME
Total Monthly Income	$
Less: Expenses	$
Funds Available:	$
Please type the numbers you see in the image below.
To Meet Goals