Be The Bank Program Questionnaire

Be-The-Bank Program

Qualification Questionnaire

Welcome to your Be-The-Bank Information Gathering Section. This questionnaire will include basic questions about yourself and some details about your debts, retirement desires, income, life insurance and other accounts. Please be as thorough as possible and/or desired. The more thorough the information the better picture you Personalized Be-The-Bank Program Report will be for you. We look forward to working with you.

First Name

Last Name

State

Phone *

Email *

Date of birth

Gender

Desired Retirement Age?

Do you want to include a Spouse/Significant Other in this Report?

Current Concerns

Any Future Expenses that you are Planning?

Do you have any children?

Spouse/Significant Other Name

Spouse/Significant Other Date of Birth

Spouse/Significant Other Desired Retirement Age?

Number of Children

Children's Ages (seperated by commas)

Mortgage Payment (P&I only)

Outstanding Mortgage Balance

Term Remaining (Years)

Current Interest Rate

Type of Mortgage

Do you have another mortgage?

2nd Mortgage Payment (P&I Only)

2nd Mortgage Outstanding Balance

2nd Mortgage Term Remaining (Years)

2nd Mortgage Interest Rate

2nd Mortgage Type

Add info about any other mortgages here:

Debt 1 Name

Debt 1 Amount Owed

Debt 1 Interest Rate (%)

Debt 1 Minimum Payment ($)

Debt 1 Actual Payment ($)

Other Debt?

Debt 2 Name

Debt 2 Amount Owed ($)

Debt 2 Interest Rate (%)

Debt 2 Minimum Payment ($)

Debt 2 Actual Payment ($)

More than 2 Debts?

Debt 3 Name

Debt 3 Amount Owed ($)

Debt 3 Interest Rate (%)

Debt 3 Minimum Payment ($)

Debt 3 Actual Payment ($)

More than 3 Debts?

Debt 4 Name

Debt 4 Amount Owed ($)

Debt 4 Interest Rate (%)

Debt 4 Minimum Payment ($)

Debt 4 Actual Payment ($)

More than 4 Debts?

Debt 5 Name

Debt 5 Amount Owed ($)

Debt 5 Interest Rate (%)

Debt 5 Minimum Payment ($)

Debt 5 Actual Payment ($)

More than 5 Debts?

Debt 6 Name

Debt 6 Amount Owed ($)

Amount 6 Interest Rate (%)

Debt 6 Minimum Payment ($)

Debt 6 Actual Payment ($)

More than 6 Debts?

Debt 7 Name

Debt 7 Amount Owed ($)

Debt 7 Interest Rate (%)

Debt 7 Minimum Payment ($)

Debt 7 Actual Payment ($)

More than 7 Debts?

Debt 8 Name

Debt 8 Amount Owed ($)

Debt 8 Interest Rate (%)

Debt 8 Minimum Payment ($)

Debt 8 Actual Payment ($)

More than 8 Debts?

Debt 9 Name

Debt 9 Amount Owed ($)

Debt 9 Interest Rate (%)

Debt 9 Minimum Payment ($)

Debt 9 Actual Payment ($)

More than 9 Debts?

Debt 10 Name

Debt 10 Amount Owed ($)

Debt 10 Interest Rate (%)

Debt 10 Minimum Payment ($)

Debt 10 Actual Payment ($)

More than 10 Debts?

Additional Debt Information

General Health of Primary Member

Are you a Tobacco user?

If Applicable, General Health of Spouse/Significant Other

If Applicable, is your Spouse/Significant Other a Tobacco User

Do you have Life Insurance?

Type of Life Insurance Policy

Death Benefit

Current Cash Value (if known)

Info about Other Life Policies (Type, Premium, Death Benefit, Cash Value)

Does your Spouse/Significant Other have Life Insurance?

Spouse/Significant Other Life Insurance Type

Spouse/Significant Other Yearly Premium Amount

Spouse/Significant Other Death Benefit

Spouse/Significant Other Cash Value (If Known)

Other Life Insurance Information for Spouse/Significant Other

Income and liquid asset information can be helpful in creating a more detailed and accurate Report. Would you like to answer income and asset questions?

The following are income questions are referring to MONTHLY Gross Income (Before Taxes).

Your Wages/Salary

Social Security Income

Pension

Investment Income

Rental Income

Other Income

Desired Retirement Income

Does your Spouse/Significant Other Receive Income? (If Not Applicable select N/A)

Spouse/Significant Other MONTHLY Wages/Salary

Spouse/Significant Other Social Security

Spouse/Significant Other Pension

Spouse/Significant Other Investment Income

Spouse/Significant Other Rental Income

Other Income for Spouse/Significant Other

Spouse/Significant Other Desired Retirement Income

Do you expect any significant change in cash flow in the near future?

If yes, Please Explain Upcoming Cash Flow Changes

Investment Accounts Include Qualified Accounts, Non-Qualified Accounts and Savings Accounts.

Do you have any Investment Accounts Including Savings?

Account 1 Financial Institution

Account 1 Type

Account 1 Value ($)

Monthly Contribution ($)

Other Accounts Info (Institution Names, Account Types, Values and Monthly Contributions)

If you are able to, roughly how much are you able to put into savings each month?

Any Additional Information or Questions you would like your Be-The-Bank Program Consultant to know?

I agree, that the information provided is a general picture of my current financial situation. I give my dedicated Be-The-Bank Program Specialist permission to contact me regarding my Personalized Report via phone, text and/or email. *

I agree