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Intake Form

"*" indicates required fields

Step 1 of 3 - Section 1 - Personal Information

INTAKE FORM

Do you have a Co-Applicant?*

Yes

Co-Client Information

*All following fields marked "CO-CLIENT" are not required unless you are considering converting a co-client’s retirement accounts and want their balances to be considered in your analysis.

First Name*

Last Name*

CO-CLIENT: First Name

CO-CLIENT: Last Name

Date of Birth*

CO-CLIENT: Date of Birth

CO-CLIENT: Relationship to Client

Phone*

Email*

State of Residence*

Are you currently retired?*

CO-CLIENT: Are you currently retired?

Age at Retirement (if not retired projected age):*

CO-CLIENT: Age at Retirement (if not retired projected age):

Federal Tax Filing Status*

CO-CLIENT: Federal Tax Filing Status

Please list your main goals & objectives (i.e., larger estate for prosperity, higher after-tax income for spouse, higher personal after-tax income, or list other )*

Section 3- Investment Assets, Savings, Real Estate & Debt

List your bank & Investment accounts including checking, taxable, 401k account, IRA account, etc.

Retirement Assets: Roth IRA

Total Roth IRA Balance

CO-CLIENT: Total Roth IRA Balance

Roth IRA Current Custodian(s)

CO-CLIENT: Roth IRA Current Custodian(s)

Roth IRA Monthly Contribution

CO-CLIENT: Roth IRA Monthly Contribution

Retirement Assets: Traditional IRA

Total Traditional IRA Balance

CO-CLIENT: Total Traditional IRA Balance

Traditional Current Custodian(s)

CO-CLIENT: Traditional Current Custodian(s)

Traditional Monthly Contribution

CO-CLIENT: Traditional Monthly Contribution

Retirement Assets: Employer- Sponsored Plan

Employer- Sponsored Plan Balance

CO-CLIENT: Employer- Sponsored Plan Balance

Employer- Sponsored Plan Current Custodian

CO-CLIENT: Employer- Sponsored Plan Current Custodian

Employer- Sponsored Plan Monthly Contribution

CO-CLIENT: Employer- Sponsored Plan Monthly Contribution

Please list any additional assets and information that you believe will be helpful (i.e., illiquid balances, surrender chargers, lock up periods, etc.)

Non-Retirement Assets

** Please do not include retirement accounts in this section

Checking, Savings, Money Market

Combined Total Balance (Cash)

CO-CLIENT: Combined Total Balance (Cash)

Monthly Contribution

CO-CLIENT: Monthly Contribution

Mutual Funds, Stocks, Bonds, Crypto, Annuities, etc.

Combined Total Balance (Brokerage)

CO-CLIENT: Combined Total Balance (Brokerage)

Monthly Contribution

Please list any additional assets and information:

Real Estate

Primary Home

Value of Primary Home

Mortgage Balance

Monthly payment (include taxes & Insurance)

Other Real Estate (combined)

Total Value of Other Real Estate

Total Mortgage Balance

Monthly Rental Income

Life Insurance

If you have one or more life insurance policies, please provide details below.

Face Value

Annual Premium Amount

CO-CLIENT: Face Value

Cash Surrender Value

CO-CLIENT: Cash Surrender Value

Additional Assets

For the following fields include co-clients’ information, if applicable

List any other additional assets not noted above and their values

List all liabilities/debt (credit cards, student loans, etc) and their values

This field is for validation purposes and should be left unchanged.

Email Us

info@rothright.com

Call Us

1-844-595-3100

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Intake Form

Intake Form

INTAKE FORM

Co-Client Information

Section 2- Income & Expenses

For the following fields include co-clients’ information, if applicable

Section 3- Investment Assets, Savings, Real Estate & Debt

Non-Retirement Assets

Real Estate

Life Insurance

Additional Assets

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Call Us

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