Student's Name(s): Cum. GPA:

High School student attends:

Parent #1/Dad’s Name:

Parent #2/Mom’s Name:

Student Age: Mother’s Age: Father’s Age:

# of Family Members in Household

# to be in College 1st year: # to be in College 2nd year:

HS Grad Year: # of siblings:

Top Colleges Interested at this time for Student

1) 2)

3) 4)

Estimated STUDENT’s Income for Calendar Year “preceding” High School graduation

W2/Earned Income $ Interest/Dividend Income $

Social Security Income (if any) $

Estimated PARENT’s Income for Calendar Year “preceding” High School graduation

Parent 1/Dad (W2 or net business income) $

Parent 2/Mom (W2 or net business income) $

Total of all Other Income other than from your job, if any $

Adjusted Gross Income (AGI: Form 1040 – bottom line of Page 1) $

Annual Contributions to Retirement Accounts (if 401k, see W2 box 12) $

Total Untaxed Income (soc. security, child support, etc) $

Monthly Mortgage $

Fed. Income Tax Paid $

Amt. Saving for College Now $ /Yr.

Amount able to pay while in college $ /Yr.

Student's Assets

Checking, Savings, CDs Total $ Stocks, Bonds (EE, or other)  $

Mutual Funds (UGMA/UTMA, Conservatorship) $

Total of younger Sibling's Assets $

Parents' Assets

Checking & Savings Total $ CDs $ Stocks $

Mutuals/Bond/529 Funds $ IRAs $ 401(k) $

Home Value $ Mortgage(s) $

Rental/Invest. Property EQUITY $ Business Value $

Business Type (S-corp, LLC, etc.)

Life Insurance Face Amount $ Cash Values $

Car Loan Debt $ Credit card debt $

Do you own all/part of a business?

Which workshop did you attend or from whom did you learn about Campus Advisers?

Please list two possible days and times you would like to have your free 30 minute phone consultation.

Email Address: RequiredPlease provide a valid email address

Telephone Number: Required