Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Are you an American citizen? *

Yes

No

Did you attend college? *

Yes

No

Have you served int the military? *

Yes

No

Have you ever been arrested or convicted of a crime? *

Yes

No

Are you presently taking any medication? *

Yes

No

Have you every been treated for emotional problems? *

Yes

No

Have you been diagnosed with any physical handicaps? *

Yes

No

Do you use any drug or alcohol substance ? *

Yes

No

Have you ever been in a Rehabilitation Center for any reason? *

Yes

No

Do you know of any reason why you cannot have a normal sex life? *

Yes

No

Do you know of any reason why conception would not be possible due to impotence or any physiological problem? *

Yes

No

Have you ever had any form of sexual disease *

Yes

No

Are you planning to have children? *

Yes

No

Have you discussed how you will handle your in-laws on holidays and what influence they will have in you marriage? *

Yes

No

Have you discussed how you will handle old friends and acquaintances from interfering in your marriage? *

Yes

No

What is the combined total balance of all your credit cards? *

I do not own a credit card

I do not have a balance on my credit card(s)

$0 -$1999

$2000 - $4999

$5000 - $9999

$10,000 - $14,999

Over $15,000

Current status of your vehicle *

I do not have a vehicle

Owned and completely paid for

Leased

Loan

Company Car

Do you owe the IRS or the court system any money? *

Yes

No

Did you file an income tax return last year? *

Yes

No

Have you ever co-signed a loan with or for anyone? (This includes; Home Mortgages, Car Lease, Bank Loans, etc.) *

Yes

No

What is your current living situation? *

I rent

I own my home

I live with family

Do you owe on medical/dental bills? *

Yes

No

Do you pay child support or alimony payments? *

Yes

No

Have you made a will? *

Yes

No

Do you have a driver’s license? *

Yes

No

Is your driver’s license suspended?

Yes

No

Do you have current auto insurance?

Yes

No

Have you ever received an inheritance or large sum of money by anyone?

Yes

No

If yes, have you discussed this with your future spouse?

Yes

No

Do you have a daily devotional time? *

Yes

No

Do you and your fiancée pray together? *

Yes

No

Have you been water baptized since you believed? *

Yes

No