Data Gathering for Financial Needs Analysis (FNA Intake Form)

HOUSEHOLD INFORMATION

Client 1 (Your details)

Full Name *

Date of birth *

Gender *

Immigration Status *

Date you achieved this immigration status (e.g. date you landed as a PR)

If you are a temporary resident, when will your status expire?

Address *

Street Address

City *

State

Country

Postal Code *

Phone *

Email *

Client 2 (Details of your spouse if married, ignore this section if you are single)

Spouse Full Name

Spouse Date of Birth

Spouse Gender

Spouse Immigration Status

Dependents

Do you have any dependents? (If yes, please complete the below)

Dependent 1

Name
DOB
Gender

Dependent 2

Name
DOB
Gender

Dependent 3

Name
DOB
Gender

Dependent 4

Name
DOB
Gender

GOALS

Check personal, professional, and financial goals that are most important and of greatest value / worth to you:

Input other goals below:

INCOME

Client 1 Total Annual Gross Income

Client 1 Source of Income

Client 2 Total Annual Gross Income

Client 2 Source of Income

Total Combined Gross Household Income

MONTHLY CASH FLOW EXPENSES

AUTO & TRANSPORTATION EXPENSES

Fuel
Insurance
Loan/Lease Payment
Parking & Tolls
Public Transportation
Service
Other

FOOD EXPENSES

Dining Out
Groceries

HEALTH & MEDICAL EXPENSES

Insurance Premiums
Prescriptions
Other

HOUSEHOLD EXPENSES

Child Care
Cleaning Services
Clothing
Educational
Gifts
Landscape Services
Personal Care
Pet Care
Sports & Lessons
Other

MORTGAGE OR RENT

Homeowners or Rental Insurance
Principle & Interest
Property Taxes
Rent
Other

DEBT SERVICE (Money you pay every month to service loans

Credit Cards
Personal Loans
Student Loans
Other

OTHER MONTHLY EXPENSES

Alimony & Child Support
Subscriptions & Memberships
Tithe / Charity
Travel & Entertainment
Other

UTILITIES

Cable
Electric
Gas
Internet
Mobile Phones
Phone
Trash Collection
Water
Other

LIABILITIES

DEBT 1

Type
Description
Original Loan Term in years
Current Balance
Interest Rate
Current Actual Payment
Minimum Payment

DEBT 2

Type
Description
Original Loan Term in years
Current Balance
Interest Rate
Current Actual Payment
Minimum Payment

DEBT 3

Type
Description
Original Loan Term in years
Current Balance
Interest Rate
Current Actual Payment
Minimum Payment

DEBT 4

Type
Description
Original Loan Term in years
Current Balance
Interest Rate
Current Actual Payment
Minimum Payment

EXISTING INSURANCE POLICIES

LIFE INSURANCE NEED

If life happened to you, what percentage (%) of your income would you want your family to keep receiving?
For how many years should that income continue for your family?
What total dollar amount should be funded for your children’s education in that situation?

Do you have any existing insurance policies?

Yes

No

Insurance 1

Insured
Owner
Beneficiary
Type
Provider
Face Amount
Premium
Frequency of Payment
Policy Year

Insurance 2

Insured
Owner
Beneficiary
Type
Provider
Face Amount
Premium
Premium Mode
Policy Year

LIST OF ASSETS

Asset 1 (Savings, Chequing, TFSA, FHSA, RESP, RRSP, Stocks, Bonds, Retirement Plan, Annuity, Real Estate Equity, others)

Name (identifier)
Type (savings, TFSA, etc)
Owner
Current Value
Monthly Additions
For Retirement or For Emergency?

Asset 2 (Savings, Chequing, TFSA, FHSA, RESP, RRSP, Stocks, Bonds, Retirement Plan, Annuity, Real Estate Equity, others)

Name (identifier)
Type (savings, TFSA, etc)
Owner
Current Value
Monthly Additions
For Retirement or For Emergency?

Asset 3 (Savings, Chequing, TFSA, FHSA, RESP, RRSP, Stocks, Bonds, Retirement Plan, Annuity, Real Estate Equity, others)

Name (identifier)
Type (savings, TFSA, etc)
Owner
Current Value
Monthly Additions
For Retirement or For Emergency?

Asset 4 (Savings, Chequing, TFSA, FHSA, RESP, RRSP, Stocks, Bonds, Retirement Plan, Annuity, Real Estate Equity, others)

Name (identifier)
Type (savings, TFSA, etc)
Owner
Current Value
Monthly Additions
For Retirement or For Emergency?

Asset 5 (Savings, Chequing, TFSA, FHSA, RESP, RRSP, Stocks, Bonds, Retirement Plan, Annuity, Real Estate Equity, others)

Name (identifier)
Type (savings, TFSA, etc)
Owner
Current Value
Monthly Additions
For Retirement or For Emergency?

RETIREMENT

Expected Retirement Age (Typically 65yrs old)

Spouse 1
Spouse 2

Life Expectancy (Typically 85yrs)

Spouse 1
Spouse 2

Monthly Retirement Need (What percentage of your current income would you need per month in retirement, expressed in today’s dollars?)

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