Education Data Form – Goldwasser

Please provide the following so we can calculate the proper amount of life insurance for your family.

Your Name

Your Email

Spouse 1

Date of Birth

Occupation

Spouse 2

Date of Birth

Occupation

Educational Funding for children(Indicate either PrivateSchool or Publicby child and grade level.)

Children

Mortgage Balance(s)

$

Other major debt

$

Desired (after tax) income for the family (exclusive ofschooling and mortgage) to maintain their standard of living:

$/month

Financial support needed for other family members

$/month

for

/years

’s Earned Income

Earned Income 1

$/month

’s Earned Income

Earned Income 2

$/month

Assets currently available to produce income for the family

Personal Life Insurance

$

Personal Disability Insurance

$

Group Life Insurance

$

Group Disability Insurance

$

Stocks/Bonds/Mutual Funds

$

Loans Due You From Others

$

Other liquid investments

$

Separate Educational Funds

$

Retirement Plan (401(k) etc.)

$

IRAs

$

Business Interest (Liquid)

$

Other (explain)

$

Explain