Financial Statements

Financial Statements Personal Information Prefix Mr. Mrs. Ms. Dr.

Client

Birth Date (mm/dd/yyyy) Email Address Address

___ / ___ / _____

Name _____________________________________

Gender M F

Phone: ( _____ ) ______ - ________

________________________________________________________________________________

_____________________________________________________________________________________

City _________________________________________ Spouse/Partner

Prefix Mr. Mrs. Ms. Dr.

Birth Date (mm/dd/yyyy) Email Address

___ / ___ / _____

State ______

Zip

_________ - __________

Name _____________________________________

Gender M F

Phone: ( _____ ) ______ - ________

________________________________________________________________________________

Relationships

Gender

Dependent

Age Dependency Ends

Relationship Type*

Relationship to Whom**

Name

Birth Date

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

_________________

___ / ___ / _____

M F Yes No

__________

___________

___________

*Aunt, Brother, Brother-in-Law, Cousin, Daughter, Daughter-in-Law, Divorced Spouse, Father, Father-in-Law, Fiancee, Friend, Godchild, Godfather, Godmother, Granddaughter, Grandfather, Grandmother, Grandson, Mother, Mother-inLaw, Nephew, Niece, Sister, Sister-in-Law, Son, Son-in-Law, Stepdaughter, Stepfather, Stepmother, Stepson, Uncle **Client, Spouse, Both

Financial Statements Questionnaire

1

Assets Provide the requested information about your current assets and liabilities Cash Assets

Description

Current Balance

Owner*

Asset 1

________________

$____________

________________

Asset 2

________________

$____________

________________

Asset 3

________________

$____________

________________

Asset 4

________________

$____________

________________

Investment Assets

Description

Current Balance

Cost Basis

Owner*

Asset 1

________________

$____________

$____________

________________

Asset 2

________________

$____________

$____________

________________

Asset 3

________________

$____________

$____________

________________

Asset 4

________________

$____________

$____________

________________

Cost Basis

Annual Income (your share)

Owner*

$___________

$__________

$_______

_______

____________

$___________

$__________

$_______

_______

____________

$___________

$__________

$_______

_______

Description

Business Type**

Current Value (your share)

Asset 1

______________

____________

Asset 2

______________

Asset 3

______________

Business/Real Estate Assets

Personal Assets

Description

Personal Type***

Current Value

Cost Basis

Owner*

Asset 1

______________

____________

$___________

$__________

Asset 2

______________

____________

$___________

$__________

__________ __________

Asset 3

______________

____________

$___________

$__________

__________

Asset 4

______________

____________

$___________

$__________

__________

Description

Current Value

Annual Contribution

Cont. Begin Year

Cont. End Year

Annual Cont. Increase Rate

Asset 1

______________

____________

$__________

_______

_______

______%

Asset 2

______________

____________

$__________

_______

_______

______%

Asset 3

______________

____________

$__________

_______

_______

______%

Education Assets

Do you want to include the value of these assets in your net worth?

Yes No

*Client, Spouse, JWTROS, Community, Tenants in Common **Real Estate Rental, Partnership, Sole Proprietorship, S Corporation, LLC, Farm, Other ***Primary Residence, Secondary Residence, Auto, Motorcycle/OHV, Recreational Vehicle, Boat, Appliances, Art & Antiques, Books & Music, Clothing, Collectibles, Furniture, Furs, Hobby & Sport, Electronics & Computer, Jewelry, Musical Instruments, Rugs, Silverware, Tools, Other Financial Statements Questionnaire

2

Goal Name

Amount Available Today from Existing Assets

Monthly Contribution

Years to Contribute

Annual Cont. Increase Rate

Annual Rate of Return

Asset 1

____________

$__________

$__________

_______

______%

______%

Asset 2

____________

$__________

$__________

_______

______%

______%

Asset 3

____________

$__________

$__________

_______

______%

______%

Accumulation Goals & Assets

Yes No

Do you want to include the value of these assets in your net worth? Retirement Plans (Client)

Description

Current Balance

Annual Personal Cont.

Annual Employer Cont.

Cont. Increase Rate

Plan Type*

$__________

$__________

$__________

______%

Asset 2

___________ ___________

$__________

$__________

$__________

______%

___________ ___________

Asset 3

___________

$__________

$__________

$__________

______%

___________

Asset 1

Retirement Plans (Spouse) Asset 1

___________

$__________

$__________

$__________

______%

___________

Asset 2

___________

$__________

$__________

$__________

______%

___________

Asset 3

___________

$__________

$__________

$__________

______%

___________

*401(k), 457, 403(b), Traditional IRA, Roth IRA, Roth 401(k), SIMPLE, SEP, Annuity, Profit Sharing, Money Purchase, After-tax, Other

Life Insurance Life Benefits (Client) Current Cash Value $______

Annual Premium $________

Owner*** ________

Beneficiary** ___________

Death Benefit $________

________

___________

$________

$______

$________

___________

________

___________

$________

$______

$________

___________ ___________

________

___________

$________

$______

$________

Asset 2

___________ ___________

________

___________

$________

$______

$________

Asset 3

___________

___________

________

___________

$________

$______

$________

Type****

Insurer Name

Asset 2

___________ ___________

___________ ___________

Asset 3

___________

Asset 1

Life Benefits (Spouse) Asset 1

**Client, Spouse, Trust, Third Party ***Client, Spouse, Trust, Community ****Group, Term, Whole Life, Universal Life, Variable Life, Other Financial Statements Questionnaire

3

Debt Obligations Obligation1

Obligation 2

Obligation 3

Description

____________________

____________________

____________________

Type*

____________________

____________________

____________________

Client Spouse Joint

Client Spouse Joint

Client Spouse Joint

$______________

$______________

$______________

Responsible party Current balance Periodic payment Payment frequency**

$______________ ____________________

Interest rate

$______________ ____________________

_________%

Collateral

$______________ ____________________

_________%

_________%

None

None

None

Investments

Investments

Investments

____________

____________

____________

*Primary Residence, Home Equity/Other Mortgage, Real Estate, Business, Invest./Consumer, Automobile, Other **Semi-Monthly, Monthly, Quarterly, Semi-Annual, Annual

Contingent Liabilities Description

Type*

Detail

Current Balance

Periodic Payment

Pmt. Freq.**

Interest Rate

Loan End Date

1.

___________

__________

________

$_______

$______

_____

_____%

________

2.

___________

__________

________

$_______

$______

_____

_____%

________

3.

___________

__________

________

$_______

$______

_____

_____%

________

*Lease, Contract, Legal Claim, Other Special Debt, Contested Income Tax Lien **Semi-Monthly, Monthly, Quarterly, Semi-Annual, Annual

Income & Expenses Annual Income

Client

Spouse

Annual earned income

$______________

$______________

What annual income do you receive from investments?

$______________

$______________

What income do you receive that is not subject to FICA?

$______________

$______________

Living Expenses* *Consider the following categories: General, Rent, Homeowners/Renters Insurance, Health Insurance, Auto Insurance, Property Tax (Real Estate/Vehicle), Home Repairs/Maintenance, Utilities, Groceries, Personal Goods, Entertainment, Clothing, Gifts, Transportation, Charitable Contributions, Child Care Description

Monthly Amount

Description

Monthly Amount

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________


4

(Living Expenses continued) Description

Monthly Amount

Description

Monthly Amount

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

_____________________________

$___________

Disability Insurance Policy 1

Policy 2

Policy 3

Client Spouse

Client Spouse

Client Spouse

Group Individual

Group Individual

Group Individual

_______________

_______________

_______________

$____________

$____________

$____________

Waiting period (days)

_______________

_______________

_______________

Length of benefit (years)

_______________

_______________

_______________

$____________

$____________

$____________

COLA%

________%

________%

________%

Percent of benefit that is taxable

________%

________%

________%

Insured Type Description Monthly benefit

Annual premium

Taxes Annual federal income tax

$____________

Annual state/local income tax

$____________

Annual Social Security tax

$____________

Current Annual Financial Commitments How much do you contribute annually to taxable retirement investments?

$____________

How much do you contribute annually toward education goals?

$____________


5

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