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CLIENT INFORMATION:

Your Name:

Email

Your Date of Birth:

Spouse Name:

Spouse Date of Birth:

Your Home Phone:

Your Cell Phone:

Spouse Home Phone:

Spouse Cell Phone:

Street Address:

City:

State:

Zip:

List Children's Names and Ages:


HOW WILL YOU USE YOUR BANKING POLICY - Check all that Apply:














DEBTS to CONVERT or TRANSFER INTO YOUR BANKING POLICY:

Cars/Recreational Vehicles:

Description

Current Balance

Interest Rate

Payment Amount

Credit Cards/Loans/Mortgages:

Description

Current Balance

Interest Rate

Payment Amount


EDUCATIONAL FUNDING:

Educational Savings Plans 529 - UTMA - UGMA - Educational IRA

(Average college cost projected to be $250,000 per student.)

Current Monthly Educational Savings: $


INVESTMENTS and RETIREMENT SAVINGS - CDs, Annuities, 401K, IRA, Stocks, Bonds

Type

Qualified Yes or No?

Monthly Contribution

Market Value

Rate/Return


YOUR CURRENT INSURANCE COVERAGE

Type - Term,Whole Life,UL

Monthly Premium

Cash Value

Notes:


How much do you currently save monthly on average?






Other: Input your average monthly savings. $


FUNDING YOUR MPG BANKING POLICY




(Minimum is the fixed contribution. All additional funds over and above the minimum are available as liquid cash for banking.)

Minimum: $

Average: $

Maximum: $


WHO SENT YOU TO THIS SITE?

(Please provide us with the name of the MPG Agent who asked you to fill in this form. Thank You)