Agent Name: Jose A Alicea
Phone: 407.334.8037
Email: fundamentosdeexito@gmail.com State of
Issue____________
Client: ____________________________________________________________________ DOB: ________ /_______
/________ Tax Bracket ____________%
Spouse: ___________________________________________________________________DOB: _______ /_______
/_________ Tax Bracket ____________%
Children:
Name: ____________________________________________________________________________
DOB: ______ /______ /__________
Name: ____________________________________________________________________________
DOB: ______ /______ /__________
Name: ____________________________________________________________________________
DOB: ______ /______ /__________
Name: ____________________________________________________________________________
DOB: ______ /______ /__________
Current Concerns: Controlling Spending Eliminating Debt Reducing
Taxes Maximizing Savings Wills/Trust Establish
Children’s education Asset Protection Estate Planning
Creating your own FamilyBank
Investment Accounts: Non-Qualified Accounts, Qualified Accounts,
Savings Accounts
List account type IRA, Roth, 401K, 403b, 457, Savings, etc .
Financial Owner Current Value Tax Status
Institution
$ Tax Deferred Tax-Free Taxable Don’t
know
Annual Contributions $ Employer Match? Yes No If yes, % Match %
Financial Owner Current Value Tax Status
Institution
$ Tax Deferred Tax-Free Taxable Don’t
know
Annual $ Employer Match? Yes No If yes, % Match %
Contributions
Financial Owner Current Value Tax Status
Institution
$ Tax Deferred Tax-Free Taxable Don’t
know
Annual $ Employer Match? Yes No If yes, % Match %
Contributions
Financial Owner Current Value Tax Status
Institution
$ Tax Deferred Tax-Free Taxable Don’t
know
Annual $ Employer Match? Yes No If yes, % Match %
Contributions
Income:
MONTHLY Gross Income Primary Spouse
Wages/Salary $___________________ $___________________
Social Security $___________________ $___________________
Pension $___________________ $___________________
Investment Income $___________________ $___________________
Rental Income $___________________ $___________________
Other Income $___________________ $___________________
Total Income $___________________ $___________________
Desired Retirement Income $___________________ $___________________
Desired Retirement Age. ____________________ ____________________
Do you expect a significant change in cash flow in the near future? Yes No If
yes, explain.
__________________________________________________________________________________________
_______________________________
Life Insurance:
General
Health:__________________________________________________________________________________
___________________ Preferred Standard Non-tobacco: Tobacco:
Permanent or Term
Yearly Premium: $_______________ Death Benefit $____________________ Cash Value
$_____________________________
Permanent or Term
Premium: $_______________________ Death Benefit $____________________ Cash Value
$_____________________________
Spouse Life Insurance:
General Health:
__________________________________________________________________________________________
___________ Preferred Standard Non-tobacco:
Tobacco:
Permanent or Term
Premium: $______________________ Death Benefit $_____________________ Cash Value
$_____________________________
Permanent or Term
Premium: $______________________ Death Benefit $_____________________ Cash Value
$_____________________________
Real Estate:
Personal Residence Information:
Mortgage Payment (P&I only) $__________________
Outstanding Mortgage $______________ Term Remaining ______ years Interest Rate:
______% Type of Mortgage (check one & circle
applicable term) Fixed
Term (30 year, 15 year, etc.) ARM (5 yrs, 7 yrs, 10 yrs, etc.) Interest Only
Other Property Owned:
Mortgage Payment (P&I only) $__________________
Outstanding Mortgage $______________ Term Remaining ______ years Interest Rate:
______% Type of Mortgage (check one & circle
applicable term)
Fixed Term (30 year, 15 year, etc.) ARM (5 yrs, 7 yrs, 10 yrs, etc.) Interest
Only
Debt Related:
Please list any outstanding debts other than mortgages
Name Amount Owed Interest Rate Minimum Payment
Actual Payment
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
_____________________ _____________________ ___________________%
_____________________ _____________________
Redirected Money
Monthly Over Payments from Debts
______________________________
Monthly Contribution to Investments
______________________________
Spending Planner (Found discretionary money)
______________________________
Amount to Pull from Qualified Accounts
______________________________
(5% to 10% a year or 72T)
Amount to Pull from non-Qualified Accounts
______________________________
1035 Exchange
______________________________
Life Ins. Premium Being Replaced Monthly
______________________________
Other Available Money (Future)
______________________________
Total:
______________________________
Producer’s thoughts on case/Health Questions:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
1. Any existing health conditions? If yes, describe........................................ Yes No
________________________________________________________________________________________________________________________________________________________________________
2. Any major medical procedures in the last 5 years? If yes, describe .......... Yes No
________________________________________________________________________________________________________________________________________________________________________
3. List any prescription drug medications. Yes No
________________________________________________________________________________________________________________________________________________________________________
Analysis Reports:
Tax Analysis Income Analysis
Debt Analysis Comparison of current strategy to alternate approaches
