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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

Roth IRA Balance

CO-CLIENT: Roth IRA Balance

Roth IRA Current Custodian

CO-CLIENT: Roth IRA Current Custodian

Roth IRA Monthly Contribution

CO-CLIENT: Roth IRA Monthly Contribution

Retirement Assets: Traditional IRA

Traditional IRA Balance

CO-CLIENT: Traditional IRA Balance

Traditional Current Custodian

CO-CLIENT: Traditional Current Custodian

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

Checking, Savings, Money Market

Combined Total Balance

CO-CLIENT: Combined Total Balance

Monthly Contribution

CO-CLIENT: Monthly Contribution

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

Combined Total Balance

CO-CLIENT: Combined Total Balance

Monthly Contribution

Please list any additional assets and information:

Real Estate

Primary Home

Value

Mortgage Balance

Monthly payment (include taxes & Insurance)

Other Real Estate (combined)

Total Value

Total Mortgage Balance

Monthly Rental Income

Life Insurance

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

Face Value

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

Phone

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

Email Us

Call Us

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