Personal Information
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First & Last Name
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Phone Number
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| Email |
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Financial Wellness Checkup Questions
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| 1. I have an emergency fund of $1,000 in a liquid account like a savings or money market account, not including checking (CD’s with maturities greater than 6 month’s don’t count): |
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Yes No
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| 2. I utilize a monthly cash flow plan (budget): |
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Yes No
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| 3. I have less than $3,000 of credit card debt: |
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Yes No
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| 4. I have a 3-6 month cash reserve fund in liquid accounts such as a Money Market or Checking and Savings account, and not mutual funds or stocks: |
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Yes No
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| 5. My monthly mortgage, including property taxes & insurance, OR my monthly rent, is less than 30%, or 1/3 of my monthly take home pay: |
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Yes No
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| 6. I am completely consumer debt free (no car loans or leases, no student loans, no home equity line or loan, nor any other personal loans): |
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Yes No
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| 7a. For people not yet fully retired: I am contributing 15% toward retirement plans (401k’s, Roth IRA’s, IRA’s, 403b’s, or 457 plans): |
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Yes No
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| 7b. For people that are retired: I am drawing less than 4% of my investments to supplement my income, or I am still setting aside money in reserves on a regular basis in retirement: |
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Yes No
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| 8. My mortgage is paid off: |
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Yes No N/A
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| 9. I meet with someone on a regular basis for financial accountability: |
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Yes No
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| 10. I give to charity or church on a regular basis: |
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Yes No
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| 11. I get stressed or concerned about the following from a financial perspective: (check off as many as apply) |
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Being able to meet my monthly obligations
Potential of losing or having lost my job
Having lost a lot of money in the market
Not having enough cash reserves in the event of a financial emergency
Fearing I’ll run out of money before I run out of time
Fearing that I won’t have enough money to live on if my spouse/significant other predeceases me
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