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
Male
Female
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Desired Retirement Age?
Do you want to include a Spouse/Significant Other in this Report?
Yes
No
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Current Concerns
Select all that apply
Controlling Spending
Eliminating Debt
Reducing Taxes
Providing for children's or grandchildren's education
Maximizing Savings
Creating your own Bank
Estate Planning and Legacy
Asset Protection
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Any Future Expenses that you are Planning?
Do you have any children?
Yes
No
Not Applicable to my current financial plan
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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
Fixed Term (30 year, 15 year, etc.)
ARM (5-yr, 7-yr, 10-yr, etc.)
Interest Only
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Do you have another mortgage?
Yes
No
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2nd Mortgage Payment (P&I Only)
2nd Mortgage Outstanding Balance
2nd Mortgage Term Remaining (Years)
2nd Mortgage Interest Rate
2nd Mortgage Type
Fixed Term
ARM
Interest Only
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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?
Yes
No
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Debt 2 Name
Debt 2 Amount Owed ($)
Debt 2 Interest Rate (%)
Debt 2 Minimum Payment ($)
Debt 2 Actual Payment ($)
More than 2 Debts?
Yes
No
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Debt 3 Name
Debt 3 Amount Owed ($)
Debt 3 Interest Rate (%)
Debt 3 Minimum Payment ($)
Debt 3 Actual Payment ($)
More than 3 Debts?
Yes
No
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Debt 4 Name
Debt 4 Amount Owed ($)
Debt 4 Interest Rate (%)
Debt 4 Minimum Payment ($)
Debt 4 Actual Payment ($)
More than 4 Debts?
Yes
No
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Debt 5 Name
Debt 5 Amount Owed ($)
Debt 5 Interest Rate (%)
Debt 5 Minimum Payment ($)
Debt 5 Actual Payment ($)
More than 5 Debts?
Yes
No
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Debt 6 Name
Debt 6 Amount Owed ($)
Amount 6 Interest Rate (%)
Debt 6 Minimum Payment ($)
Debt 6 Actual Payment ($)
More than 6 Debts?
Yes
No
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Debt 7 Name
Debt 7 Amount Owed ($)
Debt 7 Interest Rate (%)
Debt 7 Minimum Payment ($)
Debt 7 Actual Payment ($)
More than 7 Debts?
Yes
No
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Debt 8 Name
Debt 8 Amount Owed ($)
Debt 8 Interest Rate (%)
Debt 8 Minimum Payment ($)
Debt 8 Actual Payment ($)
More than 8 Debts?
Yes
No
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Debt 9 Name
Debt 9 Amount Owed ($)
Debt 9 Interest Rate (%)
Debt 9 Minimum Payment ($)
Debt 9 Actual Payment ($)
More than 9 Debts?
Yes
No
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Debt 10 Name
Debt 10 Amount Owed ($)
Debt 10 Interest Rate (%)
Debt 10 Minimum Payment ($)
Debt 10 Actual Payment ($)
More than 10 Debts?
Yes
No
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Additional Debt Information
General Health of Primary Member
Are you a Tobacco user?
Yes
No
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If Applicable, General Health of Spouse/Significant Other
If Applicable, is your Spouse/Significant Other a Tobacco User
Yes
No
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Do you have Life Insurance?
Yes
No
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Type of Life Insurance Policy
Term
Permanent
Other
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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?
Yes
No
Not Applicable
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Spouse/Significant Other Life Insurance Type
Term
Permanent
Other
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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?
Yes
No, I would rather discuss with my Be-the-Bank Expert during Meeting
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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)
Yes
No
N/A
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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?
Yes
No
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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?
Yes
No
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Account 1 Financial Institution
Account 1 Type
Checking
Savings
401k
IRA
Roth IRA
403b
457
Other
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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
