Everlast Wealth — Financial Planning Intake

1

Who You Are

Basic contact and household details for everyone involved in this plan.

Person 1 -- Primary

First name

Last name

Preferred name

Pronouns

Date of birth

Email

Phone

Zip code

Person 2 -- if applicable

First name

Last name

Preferred name

Pronouns

Date of birth

Email

Phone

Relationship to Person 1

State of residence

Number of dependents

Housing situation

How did you hear about us?

2

Health Overview

Used for insurance and long term care assessments. Helps us identify what products you may qualify for.

Person 1

Health rating (1 = poor, 10 = excellent)

Tobacco / nicotine use?

Height

Weight (lbs)

Chronic / ongoing conditions

Person 2

Health rating (1 = poor, 10 = excellent)

Tobacco / nicotine use?

Height

Weight (lbs)

Chronic / ongoing conditions

3

What Matters Most to You

Select everything that resonates. Your answers help us identify which planning areas matter most -- we'll suggest the right sections below.

👪

I want to protect the people who depend on me

Spouse, children, aging parents -- if something happened to me, I want them to be okay.

💲

I'm carrying debt that feels overwhelming

Credit cards, medical bills, loans -- I need a clear path out.

📈

I worry about what happens if I can't work

Illness, injury, or job loss -- I'm not sure how long I could cover my expenses.

🏖

I'm thinking about retirement -- am I on track?

I want to know if what I'm saving today is enough to live the life I want later.

❤

I've seen someone go through long term care -- it scared me

A parent, spouse, or loved one faced a health crisis. I don't want that to drain my savings or burden my family.

📄

I feel like I'm paying too much in taxes

There has to be a smarter way. I want strategies to keep more of what I earn.

🌟

I want to leave something behind

A legacy for my kids, a cause I care about, or a business I've built -- I want it protected.

🏫

I want to help my kids pay for college

I want a smart savings plan so they don't start life buried in student debt.

📋

I have questions about Social Security or a pension

When should I claim? Which payout option is best? I want to maximize what I've earned.

🔎

I just want a full picture of where I stand

No specific crisis -- I want a trusted advisor to review everything and tell me what I'm missing.

✓ Based on what you've shared, we recommend reviewing:

You can add or remove any area below. These are suggestions based on your answers above.

Tell us a little more -- what prompted you to reach out today?

4

Income & Cashflow

List all household income. Enter gross (before taxes) monthly amounts.

Source / employer

Owner

Type

Gross monthly ($)

Frequency

Start age (future income)

End age (if applicable)

Source / employer

Owner

Type

Gross monthly ($)

Frequency

Start age (future income)

End age (if applicable)

Source / employer

Owner

Type

Gross monthly ($)

Frequency

Start age (future income)

End age (if applicable)

5

Monthly Expenses

Would you like to provide a detailed breakdown or a quick estimate?

Quick Estimate

One total monthly number

Detailed Breakdown

Line by line by category

Estimated total monthly expenses ($)

Notes on major expenses

6

Assets & Net Worth

List all accounts and assets. Approximate values are fine.

Account / asset name

Owner

Asset type

Tax type

Annual contribution ($)

Beneficiary

Approx. value ($)

Account / asset name

Owner

Asset type

Tax type

Annual contribution ($)

Beneficiary

Approx. value ($)

Account / asset name

Owner

Asset type

Tax type

Annual contribution ($)

Beneficiary

Approx. value ($)

Net worth incl. primary residence ($)

Net worth excl. primary residence ($)

Expecting an inheritance?

Estimated inheritance amount ($)

7

Financial Priorities

Rank 1 (most important) to 7 (least important) for each person. This helps us build a plan around what matters to you -- not just the numbers.

Priority	Person 1	Person 2
Protecting principal / avoiding losses
Maximizing income
Minimizing income taxes
Receiving better returns on assets
Leaving a legacy / estate planning
Tax-advantaged income in retirement
Planning for long-term care costs

Color of Money Risk Score -- Person 1

Color of Money Risk Score -- Person 2

8

Planning Areas

Areas suggested by your discovery answers are highlighted. Toggle any area on or off -- then detailed questions will appear below each selection.

Debt Management

No Yes

Life Insurance

No Yes

Disability Insurance

No Yes

Retirement Planning

No Yes

Social Security Report

No Yes

Pension Analysis

No Yes

Long Term Care Planning

No Yes

Tax Reduction Strategy

No Yes

College Planning

No Yes

Debt Management

Creditor / account Type Balance ($) Payment/mo ($) Rate (%)

Creditor

Type

Balance ($)

Payment/mo ($)

Rate (%)

Creditor

Type

Balance ($)

Payment/mo ($)

Rate (%)

Creditor

Type

Balance ($)

Payment/mo ($)

Rate (%)

Accounts in collections?

Wage garnishments active?

Lawsuits or judgments pending?

Behind on any payments?

What is your goal for debt management?

Life Insurance

Who do you most want to protect or provide for?

When you think about the people who depend on you -- what would you most want your insurance plan to do for them?

Do you currently have life insurance?

Current coverage amount ($)

Policy type (if known)

Monthly premium ($)

Primary beneficiary

Annual household income ($)

How confident are you your current coverage is enough?

Any existing cash value or living benefits to review?

Disability Insurance

If you couldn't work tomorrow due to illness or injury -- what would happen to your family financially?

Do you have disability insurance?

Monthly DI benefit if disabled ($)

Occupation / job title

Self-employed?

How long could you cover expenses without income?

Pre-existing conditions relevant to DI?

Retirement Planning

Person 1

Currently retired?

Target / actual retirement age

Person 2

Currently retired?

Target / actual retirement age

Monthly income goal in retirement ($)

Annual cost of living adjustment (%)

Do you have a retirement income plan?

Plan accounts for inflation / healthcare?

Employer match on contributions?

Expecting an inheritance?

What concerns you most about retirement?

Social Security

Person 1

Currently receiving SS?

Monthly benefit if receiving ($)

Planned claim age

Primary Insurance Amount ($)

Years of work history

Significant employment gaps?

Person 2

Currently receiving SS?

Monthly benefit if receiving ($)

Planned claim age

Primary Insurance Amount ($)

Years of work history

Divorced (married 10+ years)?

Additional Social Security notes

Pension Analysis

Who has the pension?

Employer / plan name

Status

Years of service

Estimated monthly benefit ($)

Payout options available

Survivor benefit for spouse?

COLA on pension?

Pension questions or concerns

Long Term Care Planning

Have you ever watched someone you care about face a long-term health crisis -- and how did that shape your thinking about your own care?

If you needed long-term care, what would concern you most?

Draining my retirement savings Being a burden on my family Not being able to afford quality care Losing independence Leaving nothing for my heirs

Do you have LTC coverage now?

Current LTC monthly benefit ($)

Estimated care cost in your area -- low ($/mo)

Estimated care cost in your area -- high ($/mo)

Funding sources available for a plan

Preferred funding timeline

How much would you like the plan to cover?

Preferred care setting

Monthly benefit range -- low ($)

Monthly benefit range -- high ($)

Existing LTC, life with living benefits, or annuities to coordinate?

How would an additional LTC expense impact your retirement plan and monthly cashflow?

Tax Reduction Strategy

Filing status

Estimated annual gross income ($)

Own a business / self-employed?

Currently itemize deductions?

Taxable brokerage accounts?

Prior year tax result

RMDs started?

Interested in charitable giving strategies?

Tax concerns or goals

College Planning

Number of children to plan for

Ages of children

College savings started?

Current savings balance ($)

Monthly contribution ($)

Type of school planned for

Expected parental contribution

Other sources expected?

College planning notes

9

Existing Insurance Policies

List all current life, LTC, and disability policies -- including employer-provided coverage.

Owner

Insured

Carrier / policy name

Type

Benefit / coverage amount ($)

Cash value ($)

Beneficiary

Annual premium ($)

Owner

Insured

Carrier / policy name

Type

Benefit / coverage amount ($)

Cash value ($)

Beneficiary

Annual premium ($)

10

Estate Plan

A quick snapshot of your current estate planning situation.

Do you have an estate plan?

Do you have a trust?

Do you have a will?

Durable power of attorney?

Medical directive / living will?

Interest in charitable giving?

Years since last reviewed

Working with an estate attorney?

Estate planning notes or goals

11

A Few Final Questions

When you have a financial question, who do you typically ask?

Currently working with a financial professional?

If yes -- relative or family friend?

How often do you meet?

Timeline / urgency

Any reason not to move forward together?

Color of Money Risk Score -- Person 1

Color of Money Risk Score -- Person 2

Anything else we should know before your first planning session?

12

Document Upload

Upload anything useful -- tax returns, SS statements, policy documents, pay stubs, pension summaries, benefit statements. All files are kept confidential.

⇧

Click to upload or drag files here

PDF, images, Word, Excel -- up to 10 files

General
Groceries / food
Meals out / restaurants
Clothing
Entertainment
Health insurance premiums
Childcare / education
Child support / alimony paid
Pet needs
Club / organization dues
Retirement contributions
College savings
Vacation savings
Charitable giving
Tax preparation
Other general
Subtotal — General	$0
Residential
Rent / mortgage
Property taxes (monthly est.)
Property / homeowners insurance
HOA / association dues
Home improvements / repairs
Cleaning / gardening / pool
Subtotal — Residential	$0
Utilities
Electric
Natural gas
Water / sewage
Cable / internet
Phone service
Subtotal — Utilities	$0
Transportation
Car loan / lease payment 1
Car loan / lease payment 2
Fuel
Auto insurance
Vehicle maintenance
Subtotal — Transportation	$0
Total Monthly Expenses	$0

Intake Submitted Successfully

Contact us

801-332-9670

925-699-4085

caleb@everlastwealth.com

Information

Get in touch

Subscribe to our emailing list.

Our newsletter and other valuable insights straight to your inbox.

Join the Newsletter