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Willie Goldwasser
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Education Data Form
Education Data Form
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
Child's Name
Birth Date
Grade as of Next Sept
Grade K-4
public
private
Grade 5-8
public
private
Grade 9-12
public
private
4 years College
public
private
Graduate School
yes
no
Add Child
Remove
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
If you are human, leave this field blank.
Submit