Personal financial data form

Your Personal Analysis will help determine:

  • Whether or not your assets are properly positioned.
  • If your present method of savings and investment makes maximum use of your pre-tax and after-tax income.
  • How much capital you will need to produce a comfortable retirement income.
  • The kinds of savings and investments you will need to reach your goals.
  • How much you should set aside each month for savings and investments.
  • The potential effects of inflation on your savings and investments.
  • The kind of tax-advantaged investments best suited to your needs.
  • The monthly income your family will need in the event of your premature death.
  • The amount and type of life and disability insurance you need.

Personal Financial Data Form Introduction

Congratulations on taking the first step toward reaching your goals! It has been said, "a journey of a thousand miles begins with a single step." Completing this data form is your first step toward achieving your goals.

Before you begin you need to have a clear idea of where you are. This data form is designed to simplify, as much as possible, the gathering of your financial information. The analysis that comes from this data may provide the basis for making recommenda-tions for specific investments and other financial tools that you may consider to help meet your family's needs and achieve your goals. This analysis can only be as accurate as the information you provide.

When entering amounts, use only whole dollar numbers. If you want additional information about a particular section please call the office, or write "Please Call" in the margin or "Notes" section and you will be contacted prior to your appointment. If you prefer, you may supply copies of statements in lieu of completing the corresponding sections. If there is not enough space in a section, please make a copy of the page and clearly indicate the attachment.

Information considered critical for completing the analysis is highlighted in gray.

Family data

First Name M.I. Last Name Birth Date Sex Social Security No. Smoker
Client A
Yes
No
Client B
Yes
No
Home Address:
Street City
State Zip
Home Phone Home Fax
Business Phone:
Client A Client B
Business Fax:
Client A Client B
E-mail Address:
Client A Client B

Dependents

Name Birth Date Sex Dependents of Collage Choice Start Age Years in school % Cost You Must Pay
Children
A
B
A
B
A
B
A
B
A
B
Other
A
B
A
B
College Choice: If a choice has not been made. simply enter the type of education planned (public or private) and the approximate cost for the dependent. If you do not want to fund college or education needs enter "None."
Notes

Occupation

Occupation Employer Date Started
Client A
Retired
Self-Employed
Client B
Retired
Self-Employed
Notes:

Income

Source Client A Client B Source Client A Client B
Salary & Wages Social Security Benefits
Net Self-Employment IRA/Keogh Withdrawals
Taxable Interest Taxable Pension Income
Tax Exempt Interest Taxable Annuity Income
Dividends Non-taxable Income
Alimony Received Tax-free Income
Capital Gains Other
Rental Property Income Other
Royalty Income Other
Partnership Income Other (non cash flow)
Income from Trusts Expected Salary Increase
Notes:

Taxes

Information Client A Client B Filing Status
IRA Deduction Client A
Married Joint
Married Separate
Single
Head of Household
Keogh/SEP Deduction Client B
Married Joint
Married Separate
Single
Head of Household
Qualified Plan Contributions etc.) Prior Year Taxes:
Section 457 Federal Income
Alimony Paid State Income
Alimony Paid State Income
Other Adjustments Local income
Standard Deductions
FICA
Itemized Deductions Property
Tax Credits Other
Notes:

Budget

Monthly Amount Monthly Amount
Food Automobile Expenses & Leases
Medical Dental Rent
Entertainment Education Expenses
Charity/Gift Giving Other
Clothing Other
Home Maintenance Other
Utilities Total
Business Expenses Additional Amount You Could Save
Notes:

Debts Liabilities

Description Owner Original Amount Original Date Term Current Balance Payment Amount Payment Remaining int. Rate Insurance
Owner: Enter the abbreviation that applies to the liability: A-Client A, B-Client B, or C-Joint.
Insurance: Enter L for Life Insurance, or D for Disability Insurance on this liability. If both, enter LD.
Notes:

Money Owed You

Description Owner Original Amount Original Date First Payment Current Balance Int. Rate Payment Amount Term
Owner: Enter the abbreviation that applies to the money owed you: A-Client A. B-Client B. J-Joint Tenants, C-Tenants-in-Common, CP-Community Property, U-UTMA Uniform Transfer to Minors Act, T-Trust.
Notes:

Anticipated Future Income

Description Amount Rate of Increase Taxable Tax Basis Lump or Annual Start Year End Year Owner Spend % Invest %
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Owner: Enter the abbreviation that applies to the anticipated future income: A-Client A, B-Client B, or J-Joint Tenants.
Notes:

Retirement Assumptions

Desired Monthly, After-Tax Retirement Income (in today's dollars
Average Annual Inflation Rate
Retirement Considerations Client A Client B Client A Client B
Planned Retirement Age Are you eligible to participate in an employer-sponsored retirement plan?
Yes
No
Yes
No
Do you want Social Security included as a retirement income source?
Yes
No
Not Eligible
Reduced %
Yes
No
Not Eligible
Reduced %
 Are you a participant in the Federal Employees Retirement System or Railroad Retirement Plan?
Yes
No
Yes
No
Notes:

Retirement Plans

Plan A Description: Plan: Owner: Beneficiary:"
Plan A Investments: Type*** Value Total Return Cash Yield Annual Additions (indicate S or %)
Client Employer
Plan B Description: Plan: Owner: Beneficiary:"
Plan B Investments: Type*** Value Total Return Cash Yield Annual Additions (indicate S or %)
Client Employer
Plan C Description: Plan: Owner: Beneficiary:"
Plan C Investments: Type*** Value Total Return Cash Yield Annual Additions (indicate S or %)
Client Employer
Plan D Description: Plan: Owner: Beneficiary:"
Plan D Investments: Type*** Value Total Return Cash Yield Annual Additions (indicate S or %)
Client Employer
Plan E Description: Plan: Owner: Beneficiary:"
Plan E Investments: Type*** Value Total Return Cash Yield Annual Additions (indicate S or %)
Client Employer
*Plan: Enter the abbreviation that applies to qualified plan type: I-IRA, K-Keogh, P-Profit Sharing/401k, S-SEP-IRS/Simple, T-TSA/403b, D Deferred Comp/457, 0.0ther, R-Roth IRA.
**Owner and Beneficiary: Enter the abbreviation that applies to the owner or beneficiary of this qualified plan: A-Client A, B-Client B, CHI-Child, CHA-Charity. 0-Other.
***Type: Enter the abbreviation for each holding in this retirement account: C-Cash Holding, B-Bond, S-Stock. M-Mutual Fund. U-Unit Investment Trust, LP-Limited Partnership, T-Tangible Asset.
Notes:

Pensions

Description Partici-pant* Monthly Benefits Increase % Benefits Start at Age Death Benefit**
Lump Sum
Monthly
Lump Sum
Monthly
Lump Sum
Monthly
*Participant: Enter the client the pension applies to: A-Client A, B-Client B.
**Indicate after amount if death benefit is a L-lump sum or M-monthly payment.
Notes:

Investment assets

Name/Description Type* Owner** Value Total Return Cash Yield Annual Additions
Checking Account C
Money Market C
Savings C
Certificate of Deposit C
*Type: Enter the abbreviation for each investment asset: C-Cash Holding, B-Bond, S-Stock, M-Mutual Fund, U-Unit Investment Trust, LP-Limited Partnership, T-Tangible Asset.
**Owner: Enter the abbreviation that applies to the owner of these investment assets: A-Client A, B-Client B, J-Joint Tenants, C-Tenants-in-Common, CP-Community Property, U-UTMA Uniform Transfer to Minors Act, T-Trust.
Notes:

Investment Attitudes

Circle your opinion

1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree
Statement Opinion
I am willing to hold my investments in my portfolio for at least five years.
1 2 3 4 5
It is important that I am able to convert my investments into cash on short notice.
1 2 3 4 5
I am concerned that inflation may erode the value of my investments.
1 2 3 4 5
I am comfortable holding onto an investment during market fluctuations in order to achieve long-term objectives.
1 2 3 4 5
I am uncomfortable with the possibility that my portfolio may lose value.
1 2 3 4 5
It is important that my portfolio earns the highest overall rate of return possible.
1 2 3 4 5
I do not need current income from my investments.
1 2 3 4 5
I do not need current income from my investments.
1 2 3 4 5
It is important that my portfolio generates the maximum amount of income possible.
1 2 3 4 5
I am most comfortable when my portfolio contains many different investments.
1 2 3 4 5
Tax-advantaged investments are very important to me.
1 2 3 4 5

Annuities

Company Name Annui-tant* type** Owner* Payout Amount Cash Value Total Return Payout Type** Benefi- ciary*** Annual Additions
*Owner and Annuitant: Enter the abbreviation that applies to the annuity: A-Client A, B-Client B, 0-Other, J-Joint Tenants, C-Tenants-in-Common. CP-Community Property. U-UTMA Uniform Transfer to Minors Act, T-Trust.
**Type: Enter the abbreviation that applies to the type of annuity: F-Fixed, V-Variable.
***Payout Type: Enter the abbreviation for the type of annuity payouts: I-Immediate. D-Deferred.
****Beneficiary: Enter the abbreviation that applies to the beneficiary: A-Client A, B-Client B, CHI-Child. CHA-Charity. 0-Other.
Notes:

Business Assets

Description Owner Value Cost Basis Cost Yield Growth Rate
*Owner: Enter the abbreviation that applies to the business asset: A-Client A. B-Client B. J-Joint Tenants, C-Tenants-in-Common, CP-Community Property, U-UTMA Uniform Transfer to Minors Act, T-Trust.
Notes:

Real Estate

Section One:

Section One: Property information
Descr-iption Type* Owner"" Pur-chase Price Market Value Inprove-ments Property Tax Growth Rate Cash Yield Insur-ance
A.
B.
C.
*Type: Enter an abbreviation for the property type: P-Primary, S-Secondary, R-Recreational, I-Investment, RNT-Rental, 0-Other.
**Owner: Enter the abbreviation that applies to the real estate: A-Client A. B-Client B, J-Joint Tenants, C-Tenants-in-Common. CP-Community Property, U-UTMA Uniform Transfer to Minors Act, T-Trust.
***Insurance: Enter L for Life Insurance, or D for Disability Insurance on this property. If both enter LD.
Notes:

Real Estate

Section Two:

Mortgage information for properties listed above
Original Amount Payment Amount Current Balance Original Date Monthly Payment Term Years Interest Rate Type*
A.
B.
C.
Type: Enter A for Adjustable, or F for fixed.
Notes:

Life Insurance

Company Name Ins-ured* Type* Owner* Death Benefit Cash value Rate of Return Prem-ium Mode *** Loan Amount Loan Rate Benefi-ciary
*Insured, Owner, and Beneficiary: Enter the abbreviation that applies to the life insurance policy: A-Client A, B-Client B, CHI-Child, CHA-Charity, 0.0ther, J-Joint Tenants, C-Tenants-in-Common, CP-Community Property, U-UTMA Uniform Transfer to Minors Act. T-Trust.
**Type: Enter the abbreviation that applies to the type of insurance: GT-Group Term. T-Term, W-Whole Life, U-Universal. V-Variable, VU-Variable Universal.
***Enter an abbreviation for the premium payment mode: A-Annual, S-Semi-annual, Q-Quarterly, or M-Monthly.
Notes:

Other Insurance

Type Owner* Premium Mode ** Benefit Annual Increase Waiting Period Max. Benefit Period
Disability
Disability
Long-Term Care
Long-Term Care
Other
Other
Auto Insurance
Auto Insurance
Home Owners
Medical Insurance
*Owner: Enter the abbreviation that applies to the insurance policy: A-Client A, B-Client B
**Enter an abbreviation for the premium payment mode: A-Annual. S-Semi-annual, Q-Quarterly, or M-Monthly.
Notes:

Goals

Name/Description Amount Needed Frequency First Payment Number of Payments Amounts Saved
*Enter an abbreviation for the payment frequency: L-Lump sum, A-Annual.
Notes:

Estate Planning

Estate Planning Information Client A Client B Joint
Simple Will
Durable Power of Attorney
Lifetime Gifts
Value of Personal Property
Estimated Final Expenses
Desired Monthly, After-Tax Survivor Income # . To use current budget information, check here . 0 If you have varying survivor income objectives based upon family circumstances, enter details here:
Beginning Year How Long Explanation* Amount
Enter any additional information which may help in determining appropriate survivor income needs including person's name, specific ages. or events (include year).
Notes:

Estate Distribution

Desired Estate Distribution
What provisions have you made for distributing your estate?
Enter Values in the following fields as either Dollar Amounts or Percentages Client A Client B
Spouse
Qualified Terminable Interest Property (QTIP or QDOT)
Credit Shelter or Bypass Trust
Generation Skipping Trust
Does your will make any direct bequests?
To Family Members
To Other (non-family)
To Charity
To Charity Does your will make any additional bequests at the last death?
Enter Values in the following fields as Dollar Amounts. Last Death
To Non-family (other)
To Charity
Notes: