Confidential Financial Planning Questionnaire

Name: Date: Planner:

Contact Information
Enter personal information in this section. Individual 1 First Name Individual 2 First Name Married: Address: City !tate "i#: $ome Phone: %or& Phone: 'mail Address: Last Name Birth Date Retirement Age Last Name Birth Date Retirement Age

Personal Assets
Enter the current value of your personal assets. These values represent what the asset would be worth today if you had to sell it. If you still owe money, such as a mortgage on a residence, DO NOT subtract this amount from the value of the asset. The amount of money you own (the mortgage will be entered later. (alue Residence: (ehicles: R(-Boats: .ther: A##reciation Rate )If *no+n,

$ousehold !a/ings and In/estments

Enter your household investments. DO NOT include any "etirement #lan accounts such as I"$s or %&'(s. (alue Chec&ing Account: !a/ings Account: Money Mar&et Account: Certificate of De#osit )CDs,: 0o/ernment Bond - 12Bill: 1a3 Free Bond or Fund: Cor#orate Bond or Fund: Annuity: !toc&: !toc& Mutual Fund: Limited Partnershi#: Business: Real 'state: Note or Mortgage: 1angi4le: .ther: Monthly Additions

Retirement Accounts
)

Enter the value for the retirement plans. *e sure to enter any personal or company monthly additions for each "etirement #lan type. Individual 1 (alue 567 Deferred Com#: IRA: *eogh: 589&: Profit !haring: !'P: !IMPL' )IRA or 589&,: 1!A-58:4: R.1$ 589&: R.1$ IRA: Monthly Personal Additions Monthly Com#any Additions

Individual 2 (alue 567 Deferred Com#: IRA: *eogh: 589&: Profit !haring: !'P: !IMPL' )IRA or 589&,: 1!A-58:4: R.1$ 589&: R.1$ IRA: Monthly Personal Additions Monthly Com#any Additions

Lia4ilities
%

Enter the +oan *alance, ,onthly #ayment, and Interest rate for the following loan types. Balance Residence: Credit Card: Auto: Boat - R(: Personal: In/estment Loan: .ther: Monthly Payment Rate ;

De#endents
The following section is used to determine education costs. -hen estimating annual college costs, be sure to include housing, boo(s, and any other miscellaneous e.penses. Current Age Child<s Name Age %hen !tarting !chool Num4er of =ears Current 'ducation !a/ings College Cost Per =ear

Income
/

Enter your current yearly salary, and self0employment incomes. Enter your monthly pension and 1ocial 1ecurity benefits.

'arned Income:
Individual 1 Annual Amount Increase ; !alary: !elf 'm#loyment: Individual 2 Annual Amount Increase ;

!alary: !elf 'm#loyment:

Pension Income:
Pension 9 > Ind? 9: Monthly Amount Name: !tart Age: Monthly Amount: Annual Inc? ;: !ur/i/or ;: Monthly Amount Name: !tart Age: Monthly Amount: Annual Inc? ;: !ur/i/or ;: Increase ; Increase ; Pension 9 2 Ind? @: Monthly Amount Name: !tart Age: Monthly Amount: Annual Inc? ;: !ur/i/or ;: Monthly Amount Name: !tart Age: Monthly Amount: Annual Inc? ;: !ur/i/or ;: Increase ; Increase ;

Pension @ > Ind? 9:

Pension @ 2 Ind? @:

!ocial !ecurity Income:

Indi/idual 9: !tart Age: Monthly Benefit: Monthly Amount Increase ; Indi/idual @: !tart Age: Monthly Benefit: Monthly Amount Increase ;

1a3 Information-ItemiAed Deductions

2

Enter your filing status and the number of e.emptions that you claim. Enter any ta. deductions that you may have. Estimate any of the annual amounts. Filing !tatus 1ingle 3oint 4ead of 4ousehold

Num4er of '3em#tions: ItemiAed Deductions Charita4le Contri4utions Medical '3#ense )Not Premiums,: Miscellaneous: .ther Deducti4le Interest: Pro#erty 1a3: .ther 1a3 )Not Pro#erty,:

Annual Amount

Life Insurance
Enter any life insurance policies that are in force. *e sure to include any company insurance policies (5roup or Term in the Term amount. Individual 1 Amount Permanent: 1erm: Individual 2 Amount Permanent: 1erm: Annual Premium Cash (alue Annual Premium Cash (alue

.ther Insurance
6

This section covers any other insurance costs not paid through your employer. If both individuals are covered under one policy only include the $nnual #remium for one individual. Individual 1 Amount Auto Insurance: Medical: Long 1erm Care: $omeo+ners: Disa4ility: Individual 2 Amount Auto Insurance: Medical: Long 1erm Care: $omeo+ners: Disa4ility: Annual Premium Annual Premium

Disa4ility Co/erage
Enter the short and long0term monthly benefits you would be eligible to receive should you become disabled. These are monthly amounts paid to you. Individual 1 Personal Co/erage: Com#any Co/erage: Individual 2 Personal Co/erage: Com#any Co/erage: !hort21erm Monthly Amount Long21erm Monthly Amount !hort21erm Monthly Amount Long21erm Monthly Amount

Personal '3#enses
7

Enter any personal e.penses in the following section. This section should not include any payments from previous sections such as +oan or ,ortgage payments, Insurance #remiums, or Itemi8ed Deductions. Monthly Amount Miscellaneous:BB Clothing: 1rans#ortation: Ctilities: $ousehold: Children: Personal: 0ifts - (acations: Food:

BB Cse Miscellaneous for a single amount entry co/ering all e3#enses? Monthly Amount Pre2Retirement Inflation Rate: Post2Retirement Inflation Rates:

.ther Income-'3#enses
Enter any other Income and E.pense items in the ne.t section. 9or e.ample, you could include the future purchases of a vehicle, an inheritance that you will receive, or vacation. *e sure to use negative numbers for purchases or e.penses, and positive number for income items. !ingle =ear Name Multi#le =ear Name Annual Amount !tart Age !to# Age Annual Amount !tart Age