GLENN WOODY

                                         FINANCIAL CONSULTANTS, INC.

 

 

 

 

 

 

Confidential

Personal And Financial

Data Questionnaire

 

(Please mark in black or blue ink.)

 

 

 

 

 

 

            Client Name:                                                                     

 

                   Date:             _______________________

 

                                               

                                                                                           

 

 

 

                  

                 

                

 

 

 

This Personal and Financial Data Questionnaire is designed to help you gather all the required information for your customized financial plan.  The questionnaire's easy-to-follow format will allow you to enter your required personal data and financial details.  These items are necessary so we can create a complete and thorough picture of your current and future financial situation.

Please have the following items on hand to help you complete this questionnaire and submit them with it:

q      Your tax returns & assessments - past 2 yrs.

q      Your spouse’s tax returns & assessments - past 2 yrs.

q      Pension statement from your employer

q      Benefits statement from your employer

q      Pension statement from your spouse’s employer

q      Benefits statement from your spouse’s employer

q      Copies of business buy/sell or shareholder agreements

q      Pay stubs for each of your latest 2 pay periods

q      All life insurance and disability insurance policies

q         Latest statements from trust companies, brokers, investment companies and banks

q         Budget of your personal and living expenses – See our worksheet attached

q      Latest mortgage and other loan statements

q      Latest family trust, will, power of attorney

q      Marital agreement(s)

q      Severance pay documents

q      Other relevant documentation

 

Keep In Mind...

 

The more information you provide, the more realistic your financial plan will be.  If you are unsure of an exact value for any piece of information, please give it your best estimate. 

 

Instead of answering all of the questions, you may find it easier to provide us with copies of these documents.  Just make a note on this form that you are submitting a detailed document and then bring them to our planning meeting.

 

 

 

 

 

 

 

Glenn D. Woody

Certified Financial Planner ^TM

 

 

 

 

 

 

 

PERSONAL INFORMATION SHEET

 

Family Head Information

HEAD 1	HEAD 2
Name: __________________________________________________	Name:  __________________________________________________
Marital Status: __________________________ Sex:______________ ____________ Date of Birth: _____________________________________________ ___________                      Month                           Day                         Year	Marital Status:______________________ Sex:__________________ Date of Birth: ____________________________________________                      Month                           Day                         Year
Social Security Number: ____________________________________	Social Security Number: ____________________________________ ___________________
Street Address: __________________________________________ _____________	Street Address: __________________________________________ ____________
City:_____________________ State:__________________________	City: ____________________ State:__________________________
Country:_________________ _______ Zip Code:________________ _______ Home Phone: #____________________________________________	Country:_________________                 Zip Code:_______________ Home Phone: #___________________________________________
Occupation: _____________________________________________ __________	Occupation: _____________________________________________
Employer: _______________________________________________	Employer: _______________________________________________
Fax Phone: # _______________    Business Phone: #_____________ E-Mail: __________________________________________________	Fax Phone: # _______________    Business Phone: #_____________ E-Mail: __________________________________________________

 

Children / Dependants

Child Name #1: ___________________________________________	Child Name #2: ___________________________________________
Dependant: Yes  q No  q   Date of Birth: ____________________	Dependant: Yes  q No  q   Date of Birth: ____________________
Month        Day        Year	Month        Day        Year
Sex:   Male  q Female   q   Year in School: __________________	Sex:   Male  q Female   q   Year in School: __________________
Education Goal: ___________________________________________	Education Goal: __________________________________________
Child Name #3: ___________________________________________	Child Name #4: ___________________________________________
Dependant: Yes  q No  q   Date of Birth: ____________________	Dependant: Yes  q No  q   Date of Birth: ____________________
Month        Day        Year	Month        Day        Year
Sex:   Male  q Female   q   Year in School: __________________	Sex:   Male  q Female   q   Year in School: __________________
Education Goal: ___________________________________________	Education Goal: __________________________________________

 

Professional Advisors

Financial Advisor: ___________________________________ Glenn Woody Financial Consultants, Inc.	Financial Advisor: ______________ Glenn Woody Financial Consultants, Inc.
Attorney: ________________________________________________ ________	Attorney: _______________________________________________ _______
Accountant: _____________________________________________ __________	Accountant: _____________________________________________
Power of Attorney:________________________________________ _______________	Power of Attorney:________________________________________ ______________
Do you have a Will?: _______________________________________ _________________	Do you have a Will?: _______________________________________ ________________
Last updated on: ________________________________________	Last updated on: _______________________________________
Location of Will: __________________________________________ Do you have a Trust?_________ Last Updated on: _______________ Location of Trust: __________________________________________	Location of Will: __________________________________________ Do you have a Trust?_________ Last Updated on: _______________ Location of Trust: __________________________________________

 

 

 

 

 

 

 

 

 

 

PLANNING ASSUMPTIONS

 

 

Milestones                           Head 1                                                                                                                   Head 2

Planned Retirement Date:_ __________________________  or Age:___ ________________________________________________	Planned Retirement Date: or Age: __________________
Month       Day       Year	Month       Day       Year
Life Expectancy: __________________________________________	Life Expectancy: _________________________________________ _____________
Age / Year	Age / Year
Planning Horizon is from the current year to the Year:____________ or Age:________________________________________________	Planning Horizon is from the current year to the Year: ____ __________________________________________ or Age: _________

 

 

 

IRA Historical Data

(Use this area to enter each asset's Start of Year  account balances, as well as information regarding assets that may have come due and have not been allocated to another investment at this time.)

Cash Surplus or Deficit Start of Year Account Balance: $__________ _____________________________________________	Cash Surplus or Deficit Start of Year Account Balance: $ _________
IRA – Cash Start of Year Account Balance: $ ___________________	IRA - Start of Year Account Balance: $ ________________________
401 (k)  Start of Year Account Balance: $ _______________________	401 (k) Start of Year Account Balance: $______________________
403 (b)  Start of Year Account Balance: $ _____________________	403 (b) Start of Year Account Balance: $______________________
457 Start of Year Account Balance: $ _________________________	457 Start of Year Account Balance: $_________________________
SEP Start of Year Account Balance: $ _________________________	SEP Start of Year Account Balance: $_________________________
Roth Start of Year Account Balance: $_________________________	Roth Start of Year Account Balance: $________________________
401 (k) Start of Year Account Balance: $ ______________________ _________________________________ Beneficiaries:_________________________________ %__________                      __________________________________ %__________	401 (k) Start of Year Account Balance: $ ______________________ _________________________________ Beneficiaries:_________________________________ %__________                      __________________________________ %__________
__________________________________ %__________	__________________________________ %__________

 

 

Economic Factors

 

Inflation Rate that will be used in all financial projections:  _______%

(We default to 3%)

 

 

 

 

 

 

INCOME SOURCES

HEAD 1

HEAD 2

 

Employment

Annual Salary: $ __________________________________________ ______________	Annual Salary: $ __________________________________________ _____________
Is this salary indexed to inflation?     Yes  q +/- _____%    No  q	Is this salary indexed to inflation?     Yes  q +/- _____%    No  q

 

Retirement

Social Security

Eligible for benefits?   Yes  q No  q Start at retirement?     Yes  q At what age will these benefits begin? ________________________ Years worked to date? ____________________________________ Benefits based on average annual salary: $ ____________________ ___________________________________ Estimated Monthly Benefits: $ ________________________________

Eligible for benefits?   Yes  q No  q Start at retirement?     Yes  q At what age will these benefits begin? ________________________ Years worked to date? ____________________________________ Benefits based on average annual salary: $____________________ __________________________________ Estimated Monthly Benefits: $ _______________________________

 

Employer Defined Benefit Pension Plans

Expected Annual Pension: $ _________________________________ _______________________	Expected Annual Pension: $ ________________________________
At what age will these benefits begin? ______    Years of Service: __	At what age will these benefits begin?____________________ Years of Service: _____________________________
Pension Formula: _________________________________________ (Contribution amount is entered under Tax Related Expenses)	Pension Formula: _________________________________________ (Contribution amount is entered under Tax Related Expenses)
Is pension integrated with Social Security?     Yes  q No  q	Is pension integrated with Social Security?     Yes  q No  q
Percentage Payable to Survivor: % ________________	Percentage Payable to Survivor: % ________________

 

Retiring Allowances (Use the back of this sheet to enter additional details)

Retiring Allowance: $ ___________ Eligible Amount: $______________	Retiring Allowance: $ ___________    Eligible Amount: $____________
Will it be transferred to an IRA?     Yes  q No  q	Will it be transferred to an IRA?     Yes  q No  q
Will it be indexed to inflation?            Yes  q No  q	Will it be indexed to inflation?            Yes  q No  q
Date received: ____________________________________________ ____________	Date received: ____________________________________________
Month       Day       Year	Month       Day       Year

 

 

Miscellaneous Income  (Use the back of this sheet to enter additional details)

Employment Bonus: $ ______________________________________	Employment Bonus: $______________________________________
Self-Employment Earned: $ __________________________________	Self-Employment Earned: $ _________________________________
Self Employed Commission: $ ________________________________	Self Employed Commission: $ ________________________________
Alimony: $ _______________________________________________ _________	Alimony: $ _______________________________________________ ________
Child Support: $ __________________________________________ Tax Free Income: $ ________________________________________ ________________	Child Support: $ __________________________________________ Tax Free Income: $ ________________________________________
Other:_________________________ $________________________	Other: ________________________  $________________________
______________________________  $ ________________________ ______________________________	_____________________________  $ ________________________ _____________________________

EXPENSES

HEAD 1

HEAD 2

 

Non-Tax Related

Lifestyle   (If you share your common lifestyle expenses, just enter the total for one person) (Use our worksheet to help compile expenses)

 

Annual Lifestyle: $ ________________________________________	Annual Lifestyle: $ ________________________________________
(Excluding mortgage payments, but including rent, water, heating, phone, etc., and property taxes if not included in mortgage payments.) By what percentage do you expect this expense to increase/decrease	(Excluding mortgage payments, but including rent, water, heating, phone, etc., and property taxes if not included in mortgage payments.) By what percentage do you expect this expense to increase/decrease
during retirement?  ________%	during retirement?  ________%

 

(The following section is optional and can be used if you wish to break down the Annual Lifestyle total above)

Housing: $_______________________ Food: $ _________________	Housing: $_______________________ Food: $_________________
Transportation: $ _________________  Personal: $______________	Transportation: $____________________________ Personal: $ ____ _____________
Entertainment: $ __________________________________________	Entertainment: $ __________________________________________

 

Semi-Regular Expenses   (Optional)

 

I plan to upgrade my automobile every: ________________ years.	I plan to upgrade my automobile every: __________            years.
I usually spend approx. $ ______________   for the upgrade.	I usually spend approx. $ _______________           for the upgrade.
I plan to wait: _________   years before my next car upgrade.	I plan to wait: _________  years before my next car upgrade.
I plan to take a vacation every: _____________________     years.	I plan to take a vacation every: ____________________ years.
I usually spend approx. $_________________   for the vacation.	I usually spend approx. $ _________________    for the vacation.
I plan to wait: _________ years before taking my next vacation.	I plan to wait:__________       years before taking my next vacation.

 

Tax Related

 

Charitable Contributions: $ __________________________________	Charitable Contributions: $ __________________________________
Medical / Dental: $ _________________________________________	Medical / Dental: $ ________________________________________
Child Care: $ _____________________________________________	Child Care: $ _____________________________________________
Carrying Charges: $ _______________________________________	Carrying Charges: $ _______________________________________ ________________
Professional / Union Dues: $ ________________________________	Professional / Union Dues: $_________________________________ ______________________
Defined Benefit: $ _________________________________________ _______________	Defined Benefit: $ _________________________________________ ______________
Other: ________________________ $_________________________	Other: _________________________ $________________________
______________________________ $ ________________________	____________________________   $________________________

Any Other Lifestyle Expense Details

Name: ______________________________ Amount: $___________________   every/on____________________

Name: ______________________________ Amount: $ ____________________________   every/on ___________        

Name: ______________________________ Amount: $ ____________________________   every/on ___________        

ASSETS

 

House and Mortgage

 

House  (Principal residence only - Real Estate assets will be defined later)

 

Purchase Amount:  $ ____________      Purchase Date: _____________  Who is the house's owner?   Head 1 q   Head 2 q   Joint q

What is its current market value?  $ ____________________________________________________    What is its expected growth rate? %               _____________________________  

Mortgage  (For the Above Residence)

 

(Property taxes are excluded from Principal & Interest payments in the program.)

Original Principal: $ ______________    Start Date: __________________ Who is the mortgage's owner?   Head 1 q   Head 2 q   Joint q

                                                                                      Month   Day   Year

Mortgage's interest rate: % ___________________________________  Mortgage is amortized for:                   years from:  today q   loan start date q.

I/we make regular principal and interest payments on a  ___________________________                   basis.

                                                                                       (e.g. Weekly, Monthly, Yearly, etc.)

As of: ________________________ there is still: $                                                                  outstanding on the mortgage.

                  Month    Day    Year

Is the mortgage insured?         Yes q     No q

 

 

Non-Qualified Investment Assets

(Enter each asset type's aggregate value as of the start of the year.  Break down each asset’s expected return rate based on its return component - e.g. If a Mutual Fund asset is earning 2% Interest, 2% Dividends, 4% Capital Gains and 4% Deferred Capital Gains,  you would enter  2-I, 2-D, 4-CG, 4-DCG.  Or, you may prefer to include investment statements for any or all of this section.)

 

HEAD 1

Mut. Funds:       $__________________     ACB: $     ____________________     Return: %  __________________________

CDs:                  $__________________     Term:       ____________________     Return: %  __________________________

Stocks:              $__________________     ACB: $     ____________________     Return: %  __________________________

Bonds:               $__________________     ACB: $     ____________________     Return: %  __________________________

T-Bills

(Face Value):    $_______________ Market Value: $____________________           ACB:    $________________     Maturity:_____________________

Bank Deposits:_ $ _________________________________________________ Return: %  __________________________

Real Estate:       $_______________ Market Value: $____________________           ACB:    $________________     Pur. Date:____________________

                          $_______________ Market Value: $____________________           ACB:    $________________     Pur. Date:____________________

Lifestyle:           $_______________ Return: %_________________________           ACB:    $________________     Sale Date:___________________

Other:                $_______________ Return: %_________________________           ACB:    $________________     Return: %____________________

 

 

Note:   “ACB”  means Average Cost Basis
Non-Qualified Investment Assets (con’t)

(Enter each asset type's aggregate value as of the start of the year.  Break down each asset’s expected return rate based on its return component - e.g. If a Mutual Fund asset is earning 2% Interest, 2% Dividends, 4% Capital Gains and 4% Deferred Capital Gains,  you would enter  2-I, 2-D, 4-CG, 4-DCG.  Or, you may prefer to include investment statements for any or all of this section.)

 

HEAD 2

Mut. Funds:       $__________________     ACB: $     ____________________     Return: %  __________________________

CDs:                  $__________________     Term:       ____________________     Return: %  __________________________

Stocks:              $__________________     ACB: $     ____________________     Return: %  __________________________

Bonds:               $__________________     ACB: $     ____________________     Return: %  __________________________

T-Bills

(Face Value):    $_______________ Market Value: $____________________           ACB:    $________________     Maturity:_____________________

Bank Deposits:_ $________________________________________________    Return: %  ___________________________                                        

Real Estate:       $_______________ Market Value: $____________________           ACB:    $________________     Pur. Date:____________________

                          $_______________ Market Value: $____________________           ACB:    $________________     Pur. Date:____________________

Lifestyle:           $_______________ Return: %_________________________           ACB:    $________________     Sale Date:___________________

Other:                $_______________ Return: %_________________________           ACB:    $________________     Return: %____________________

 

JOINT

Mut. Funds:       $__________________     ACB: $     ____________________     Return: %  __________________________

CDs:                  $__________________     Term:       ____________________     Return: %  __________________________

Stocks:              $__________________     ACB: $     ____________________     Return: %  __________________________

Bonds:               $__________________     ACB: $     ____________________     Return: %  __________________________

T-Bills

(Face Value):    $_______________ Market Value: $____________________           ACB:    $________________     Maturity:_____________________

Bank Deposits:_ $__________________________________________________ Return: % ___________________________

Real Estate:       $_______________ Market Value: $____________________           ACB:    $________________     Pur. Date:____________________

                          $_______________ Market Value: $____________________           ACB:    $________________     Pur. Date:____________________

Lifestyle:           $_______________ Return: %_________________________           ACB:    $________________     Sale Date:___________________

Other:                $_______________ Return: %_________________________           ACB:    $________________     Return: %____________________

 

Note:   “ACB”  means Average Cost Basis

 

 

 

 

 

 

 

 

 

 

 

Qualified Investment Assets

(Enter each asset type's aggregate value as of the start of the year. To be complete, enter return rates for the eventual transfer or conversion of an asset.  E.g. Enter an expected RRIF return rate.)

HEAD 1	HEAD 2
IRAs: $_______________________ Return: %__________________	IRAs: $_______________________ Return: %__________________
Spousal: $ _____________________  Return: %_________________ _________	Spousal: $ ___________________  Return: %__________________
Roth IRAs: $ __________________  Return: % __________________ ___________	Roth IRAs: $ __________________  Return: % _________________
Spousal Roth IRAs: $ ______________________ Return: %__________________	Spousal Roth IRAs: $ ______________________ Return: %__________________
401(k)s: $____________________ Return: %__________________	401(k)s: $____________________ Return: %__________________
403(b)s:$_____________________ Return: %	403(b)s: $____________________ Return: %__________________
457s:$_______________________ Return: % __________________ ______	457s:$_______________________ Return: % __________________ _____
SEPs: $______________________ Return: % __________________ ______	SEPs: $______________________ Return: %__________________
Keoghs: $ ____________________  Return: % __________________ ________	Keoghs: $ ____________________  Return: % __________________ _______

 

Deferred Annuities  (Enter additional annuities on the back of this sheet)

Fixed Annuity #1

Type:  _______________________________________________________________________ Payment Frequency:  ______________________

                     (e.g. Amount Certain, Term Certain, Life Income, etc.)                                                                      (e.g. Annually, Monthly, etc.)

Ownership: ________________________________________________    Annuitant(s):    Head 1 q    Head 2 q    Joint q

Payment per $1000: $ ________________   Annually q   Monthly q____ Beneficiary: _______________________________________

Start Date: ________________   Guaranteed Number of Years: ______     Account type:   General q   Separate q

Cost Basis: $ _________________________________________________ Start of Year Basis: $ _______________________________________

Additional Information: __________________________________________________________________________________________________

                                            (e.g. Initial Premiums, Start of Year Market Value, Premiums Paid, Surrender Charges ,Free Withdrawals, etc.)

 

Fixed Annuity #2

Type:  _______________________________________________________________________ Payment Frequency:  ______________________

                     (e.g. Amount Certain, Term Certain, Life Income, etc.)                                                                      (e.g. Annually, Monthly, etc.)

Ownership: ________________________________________________    Annuitant(s):    Head 1 q    Head 2 q    Joint q

Payment per $1000: $ ________________   Annually q   Monthly q____ Beneficiary: _______________________________________

Start Date: ________________   Guaranteed Number of Years: ______     Account type:   General q   Separate q

Cost Basis: $ _________________________________________________ Start of Year Basis: $ _______________________________________

Additional Information: __________________________________________________________________________________________________

                                            (e.g. Initial Premiums, Start of Year Market Value, Premiums Paid, Surrender Charges ,Free Withdrawals, etc.)

 

 

 

 

 

 

 

 

Variable Annuity #1

Type:  _______________________________________________________________________ Payment Frequency:  ______________________

                     (e.g. Amount Certain, Term Certain, Life Income, etc.)                                                                      (e.g. Annually, Monthly, etc.)

Ownership: ________________________________________________    Annuitant(s):    Head 1 q    Head 2 q    Joint q

Payment per $1000: $ ________________   Annually q   Monthly q____ Beneficiary: _______________________________________

Start Date: ________________   Guaranteed Number of Years: ______     Account type:   General q   Separate q

Cost Basis: $ _________________________________________________ Start of Year Basis: $ _______________________________________

Additional Information: __________________________________________________________________________________________________

                                            (e.g. Initial Premiums, Start of Year Market Value, Premiums Paid, Surrender Charges ,Free Withdrawals, etc.)

 

Variable Annuity #2

Type:  _______________________________________________________________________ Payment Frequency:  ______________________

                     (e.g. Amount Certain, Term Certain, Life Income, etc.)                                                                      (e.g. Annually, Monthly, etc.)

Ownership: ________________________________________________    Annuitant(s):    Head 1 q    Head 2 q    Joint q

Payment per $1000: $ ________________   Annually q   Monthly q____ Beneficiary: _______________________________________

Start Date: ________________   Guaranteed Number of Years: ______     Account type:   General q   Separate q

Cost Basis: $ _________________________________________________ Start of Year Basis: $ _______________________________________

Additional Information: __________________________________________________________________________________________________

                                            (e.g. Initial Premiums, Start of Year Market Value, Premiums Paid, Surrender Charges ,Free Withdrawals, etc.)

 

Variable Annuity #3

Type:  _______________________________________________________________________ Payment Frequency:  ______________________

                     (e.g. Amount Certain, Term Certain, Life Income, etc.)                                                                      (e.g. Annually, Monthly, etc.)

Ownership: ________________________________________________    Annuitant(s):    Head 1 q    Head 2 q    Joint q

Payment per $1000: $ ________________   Annually q   Monthly q____ Beneficiary: _______________________________________

Start Date: ________________   Guaranteed Number of Years: ______     Account type:   General q   Separate q

Cost Basis: $ _________________________________________________ Start of Year Basis: $ _______________________________________

Additional Information: __________________________________________________________________________________________________

                                            (e.g. Initial Premiums, Start of Year Market Value, Premiums Paid, Surrender Charges ,Free Withdrawals, etc.)

 

Variable Annuity #4

Type:  _______________________________________________________________________ Payment Frequency:  ______________________

                     (e.g. Amount Certain, Term Certain, Life Income, etc.)                                                                      (e.g. Annually, Monthly, etc.)

Ownership: ________________________________________________    Annuitant(s):    Head 1 q    Head 2 q    Joint q

Payment per $1000: $ ________________   Annually q   Monthly q____ Beneficiary: _______________________________________

Start Date: ________________   Guaranteed Number of Years: ______     Account type:   General q   Separate q

Cost Basis: $ _________________________________________________ Start of Year Basis: $ _______________________________________

Additional Information: __________________________________________________________________________________________________

                                            (e.g. Initial Premiums, Start of Year Market Value, Premiums Paid, Surrender Charges ,Free Withdrawals, etc.)

Personal Use Assets

 

 

Residence  (Principal residence only)

 

Asset Name: _____________________________________________          

Purchase Date:___________________________________________           Purchase Amount: $_______________________________________

Who is the primary owner?   Head 1 q   Head 2 q   Joint q      What is its expected growth rate?  % _________________________

Current Value: $ ______________    As of:_____________________           Projected Sale Date: _______________________________________

                                                                         Month     Day     Year

 

 

 

Other

Personal Use Property q Listed Personal Property q Cottage q

Asset Name: _____________________________________________          

Purchase Date:___________________________________________           Purchase Amount: $_______________________________________

Who is the primary owner?   Head 1 q   Head 2 q   Joint q      What is its expected growth rate?  % _________________________

Current Value: $ ______________    As of:_____________________           Projected Sale Date: _______________________________________

                                                                         Month     Day     Year

 

 

 

Other

Personal Use Property q Listed Personal Property q Cottage q

Asset Name: _____________________________________________          

Purchase Date:___________________________________________           Purchase Amount: $_______________________________________

Who is the primary owner?   Head 1 q   Head 2 q   Joint q      What is its expected growth rate?  % _________________________

Current Value: $ ______________    As of:_____________________           Projected Sale Date: _______________________________________

                                                                         Month     Day     Year

 

Other

Personal Use Property q Listed Personal Property q Cottage q

Asset Name: _____________________________________________          

Purchase Date:___________________________________________           Purchase Amount: $_______________________________________

Who is the primary owner?   Head 1 q   Head 2 q   Joint q      What is its expected growth rate?  % _________________________

Current Value: $ ______________    As of:_____________________           Projected Sale Date: _______________________________________

                                                                         Month     Day     Year

                                                                        
LIABILITIES

 

Personal Loans   (Enter additional loans on the back of this sheet)

 

Loan #1

Description:______________________________________________________________________________________

Original Principal: $ _________________   Who owns the loan?     Head 1 q    Head 2 q    Joint Ownership q

Loan Start Date: ___________________    Payment Type: _________________________    Interest Rate:  % _________

                               Month   Day   Year                                (e.g. Interest Only, P.I.T., etc.)

Payment Frequency: ________________________    This loan is amortized for  _______________   years

                                   (e.g. Monthly, Weekly, etc.)

Amortization Start Date:_________________________________ Amortization End Date:_________________________                                

                                                        Month   Day   Year                                                               Month   Day   Year

There is: $ _______________  still outstanding on this loan as of: ___________________________

                                                                                                             Month        Day        Year

Is this loan insured?     Yes  q  No  q     Bring into Cash flow?     Yes  q  No  q

Other information: _________________________________________________________________________________                

________________________________________________________________________________________________

 

Loan #2

Description:______________________________________________________________________________________

Original Principal: $ _________________   Who owns the loan?     Head 1 q    Head 2 q    Joint Ownership q

Loan Start Date: ___________________    Payment Type: _________________________    Interest Rate:  % _________

                               Month   Day   Year                                (e.g. Interest Only, P.I.T., etc.)

Payment Frequency: ________________________    This loan is amortized for  _______________   years

                                   (e.g. Monthly, Weekly, etc.)

Amortization Start Date: ________________________________ Amortization End Date: _________________________

                                                        Month   Day   Year                                                               Month   Day   Year

There is: $ _______________  still outstanding on this loan as of: ___________________________

                                                                                                             Month        Day        Year

Is this loan insured?     Yes  q  No  q     Bring into Cash flow?     Yes  q  No  q

Other information: _________________________________________________________________________________                

 

Loan #3

Description:______________________________________________________________________________________

Original Principal: $ _________________   Who owns the loan?     Head 1 q    Head 2 q    Joint Ownership q

Loan Start Date: ___________________    Payment Type: _________________________    Interest Rate:  % _________

                               Month   Day   Year                                (e.g. Interest Only, P.I.T., etc.)

Payment Frequency: ________________________    This loan is amortized for  _______________   years

                                   (e.g. Monthly, Weekly, etc.)

Amortization Start Date: ________________________________ Amortization End Date: _________________________

                                                        Month   Day   Year                                                               Month   Day   Year

There is: $ _______________  still outstanding on this loan as of: ___________________________

                                                                                                             Month        Day        Year

Is this loan insured?     Yes  q  No  q     Bring into Cash flow?     Yes  q  No  q

Other information: _________________________________________________________________________________                                
INSURANCE

 

Life Insurance   (Enter additional life insurance policies on the back of this sheet)

 

Policy #1

Type:___________________________________________         Policy Name: _________________________________________

Insured: _________________________________________         Beneficiary: _________________________________________

Premium Payer:___________________________________         Original Death Benefit: $ ________________________________

Premiums: $______________________________________         Payment Frequency: ___________________________________

Cash Surrender Value: $ ___________________________         Coverage applies until age: _____________________________

Other: __________________________________________________________________________________________________                

Policy #2

Type:___________________________________________         Policy Name: _________________________________________

Insured: _________________________________________         Beneficiary: _________________________________________

Premium Payer:___________________________________         Original Death Benefit: $ ________________________________

Premiums: $______________________________________         Payment Frequency: ___________________________________

Cash Surrender Value: $ ___________________________         Coverage applies until age: _____________________________

Other: __________________________________________________________________________________________________

 

Policy #3

Type:___________________________________________         Policy Name: _________________________________________

Insured: _________________________________________         Beneficiary: _________________________________________

Premium Payer:___________________________________         Original Death Benefit: $ ________________________________

Premiums: $______________________________________         Payment Frequency: ___________________________________

Cash Surrender Value: $ ___________________________         Coverage applies until age: _____________________________

Other: __________________________________________________________________________________________________

 

Disability Insurance   (Enter additional disability insurance policies on the back of this sheet)

 

Head 1: _________________________________________

Monthly Benefit: $_________________________________         Monthly Premium: $ ____________________________________

Coverage applies until age: _________________________        

 

Head 2: _________________________________________

Monthly Benefit: $_________________________________         Monthly Premium: $ ____________________________________

Coverage applies until age: _________________________        

MISCELLANEOUS TAXES

 

Miscellaneous Deductions

Taxable Income:

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

Net Income:

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

 

Miscellaneous Credits

Refundable:

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

Non-Refundable:

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

Family Member:___________________________________         Description: __________________________________________

Applicable Period:_________________________________         Amount: $___________________________________________

 

CURRENT PLANNING STRATEGIES

 

Use this section to tell us about any planning strategies that you are currently applying (e.g. Regular Savings to an investment, additional payments towards a loan’s principal, etc).  Use the back of this sheet to enter additional plans.

 

Regular Savings Plans   (Savings made on a regular, periodic basis)

 

Asset Name	Amount $	Frequency (e.g. monthly, weekly)	Indexed to Inflation?	When is this Transaction Applicable? (While I’m Working, While I’m Retired, Both, Other - e.g.  Jan. 1990 - Dec 2025)

 

Lump Sum Savings Plans   (Savings made in one or more lump sums)

 

Asset Name	Amount $	Indexed to Inflation?	When is this Transaction Applicable? (Upon Retirement, Upon Disability, Upon Death, Other - e.g.  Jan. 15, 1998)

 

Employer Sponsored Qualified Pension Plans   (Savings put into plans that are established by the employer.)

 

Asset Name	Constrained by Cash Flow?	Time of Year	When is this Transaction Applicable? (While Working, Until Age 71, Other - e.g.  Jan 1, 1995 to Dec 31, 2025 )

 

Surplus Cash Plans   (Savings made using surplus cash when available.)

Asset Name	Percentage of Surplus Cash to be Used in Purchase %	When is this Transaction Applicable? (While I’m Working, While I’m Retired, Both, Other - e.g.  Jan. 1990 - Dec 2025)

 

Regular Debt Reduction Plans           (Any payments made directly toward the principal of an existing loan.  These are over and above the required payments that are automatically defined for the liability.)

Liability Name	Amount $	Frequency (e.g. monthly, weekly)	Indexed to Inflation?	When is this Transaction Applicable? (While I’m Working, While I’m Retired, Both, Other - e.g.  Jan. 1990 - Dec 2025)

 

Lump Sum Debt Reduction             (Payments made in one or more lump sums toward the principal of an existing loan.  These are over and above the required payments that are automatically defined for the liability.)

Liability Name	Amount $	Indexed to Inflation?	When is this Transaction Applicable? (Upon Retirement, Upon Disability, Upon Death, Other - e.g.  Jan. 15, 1998)

 

Surplus Cash Debt Reduction        (Payments made toward the principal of an existing loan using surplus cash.  These are over and above the required payments that are automatically defined for the liability.)

Liability Name	Maximum Dollar Amount that can be Paid Down $	When is this Transaction Applicable? (While I’m Working, While I’m Retired, Both, Other - e.g.  Jan. 1990 - Dec 2025)

Regular Asset Redemption Plans              (Any distributions from an asset made on a periodic basis.)

Asset Name	Amount $	Frequency (e.g. monthly, weekly)	Indexed to Inflation?	When is this Transaction Applicable? (While I’m Working, While I’m Retired, Both, Other - e.g.  Jan. 1990 - Dec 2025)

 

Lump Sum Asset Redemption               (Distributions from an asset in one or more lump sums)

Asset Name	Amount $	Indexed to Inflation?	When is this Transaction Applicable? (Upon Retirement, Upon Disability, Upon Death, Other - e.g.  Jan. 15, 1998)

 

Complete Regular Asset Redemption         (Distributions from an asset that will completely use it up at the end of a defined period)

Asset Name	Frequency of Sells (e.g. Annually, Monthly,)	Indexed to Inflation?	When is this Transaction Applicable? (While I’m Working, While I’m Retired, Both, Other - e.g.  Jan. 1990 - Dec 2025)

 

Asset Transfers                 (The transfer of funds from one asset to another)

Source Asset	Destination Asset	Amount $	When is this Transaction Applicable? (Upon Retirement, Upon Disability, Upon Death, Other - e.g.  Jan. 15, 1998)

 

Leverage Investments                     (Any loans taken out for the purposes of investing)

 

Liability Name	Asset Name	Amount $	Transaction Date	Units to Buy  (Original  if asset is new or Additional if asset already exists)