Would you like to receive a complimentary copy of your in-file credit report and your county tax appraisal values each year when we perform this review?  YES NO

Have there been any significant changes in your employment or income in the past 12 months, or do you expect any in the near future?    YES NO

If yes please explain the amounts and the elements such as base salary, commissions or any other info on the lines below:

Have there been any significant changes in you savings, checking, investment or other asset balances in the last 12 months, or expect any? YES NO

If yes, please explain the amounts and their elements such as additions or subtractions:

Have you incurred any new debt that will remain open for more than 10 months?  
YES NO

If yes explain the amount and types :

Have you paid off any existing debt in the last 12 months?

YES NO

If yes please explain the amounts and type:

What are your real estate goals and dream in the next

3 to 5 years?

5 to 10 Years?

Ten years Plus?

On a scale of 1 to 10 with 10 being best how would you rate your relationship with your:
CPA                         1 2 3 4 5 6 7 8 9 10

Financial Planner     1 2 3 4 5 6 7 8 9 10

Insurance Agent     1 2 3 4 5 6 7 8 9 10

Real Estate Agent   1 2 3 4 5 6 7 8 9 10

Banker                     1 2 3 4 5 6 7 8 9 10

Are there any needs you have right now that we can help you fulfill through the confident referral to any one of our professional partners?
YES NO

Would you like for us to contact you? YES NO

If so, what is the best way to contact you? Phone Email

Name:

Address:

City,State, Zip:

Phone:

Email:

Do you currently know of anyone who is thinking about Refinancing or buying a new home in the next 12 months?

YES NO Refinance Purchase

May we have their name and phone number?

Each year we will repeat this process so that we can at anytime in the future be fully prepared to assist you with your goals and needs.  Thank you for letting us serve you.