Confidential
Financial Planning
Questionnaire

Name:	     	
Date:	     	
Planner:	     	

Contact Information

Enter personal information in this section.

Individual 1				
First Name	Last Name	Birth Date	Retirement Age	
     	     	     	     	

Individual 2				
First Name	Last Name	Birth Date	Retirement Age	
     	     	     	     	

  Married:  

Address:	     	
City, State, Zip:	     	
Home Phone:	     	
Work Phone:	     	
Email Address:	     	

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.  

	Value	Appreciation Rate (If Known)	
Residence:	     	     	
Vehicles:	     	     	
RV/Boats:	     	     	
Other:	     	     	

Household Savings and Investments

Enter your household investments.  DO NOT include any Retirement Plan accounts such as IRAs or 401ks.

	Value	Monthly Additions	
Checking Account:	     	     	
Savings Account:	     	     	
Money Market Account:	     	     	
Certificate of Deposit (CDs):	     	     	
Government Bond / T-Bill:	     	     	
Tax Free Bond or Fund:	     	     	
Corporate Bond or Fund:	     	     	
Annuity:	     	     	
Stock:	     	     	
Stock Mutual Fund:	     	     	
Limited Partnership:	     	     	
Business:	     	     	
Real Estate:	     	     	
Note or Mortgage:	     	     	
Tangible:	     	     	
Other:	     	     	

Retirement Accounts

Enter the value for the retirement plans.  Be sure to enter any personal or company monthly additions for each Retirement Plan type. 

Individual 1				
	
Value	Monthly
Personal Additions	Monthly 
Company Additions	
457 Deferred Comp:	     	     	     	
IRA:	     	     	     	
Keogh:	     	     	     	
401k:	     	     	     	
Profit Sharing:	     	     	     	
SEP:	     	     	     	
SIMPLE (IRA or 401k):	     	     	     	
TSA/403b:	     	     	     	
ROTH 401k:	     	     	     	
ROTH IRA:	     	     	     	

Individual 2				
	
Value	Monthly
Personal Additions	Monthly 
Company Additions	
457 Deferred Comp:	     	     	     	
IRA:	     	     	     	
Keogh:	     	     	     	
401k:	     	     	     	
Profit Sharing:	     	     	     	
SEP:	     	     	     	
SIMPLE (IRA or 401k):	     	     	     	
TSA/403b:	     	     	     	
ROTH 401k:	     	     	     	
ROTH IRA:	     	     	     	

Liabilities

Enter the Loan Balance, Monthly Payment, and Interest rate for the following loan types.

	Balance	Monthly Payment	Rate %	
Residence:	     	     	     	
Credit Card:	     	     	     	
Auto:	     	     	     	
Boat / RV:	     	     	     	
Personal:	     	     	     	
Investment Loan:	     	     	     	
Other:	     	     	     	

Dependents

The following section is used to determine education costs.  When estimating annual college costs, be sure to include housing, books, and any other miscellaneous expenses.  

Child’s Name	Current Age	Age When Starting School	Number of Years	Current Education Savings	College Cost Per Year	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	

Income

Enter your current yearly salary, and self-employment incomes.  Enter your monthly pension and Social Security benefits.  

Earned Income:

Individual 1				Individual 2			
 	Annual Amount	Increase %			Annual Amount	Increase %	
Salary:	     	     		Salary:	     	     	
Self Employment:	     	     		Self Employment:	     	     	

Pension Income:

Pension 1 – Ind. 1:	Monthly Amount	Increase %		Pension 1 - Ind. 2:	Monthly Amount	Increase %	
Name:	     	     		Name:	     	     	
Start Age:	     	     		Start Age:	     	     	
Monthly Amount:	     	     		Monthly Amount:	     	     	
Annual Inc. %:	     	     		Annual Inc. %:	     	     	
Survivor %:	     	     		Survivor %:	     	     	

Pension 2 – Ind. 1:	Monthly Amount	Increase %		Pension 2 - Ind. 2:	Monthly Amount	Increase %	
Name:	     	     		Name:	     	     	
Start Age:	     	     		Start Age:	     	     	
Monthly Amount:	     	     		Monthly Amount:	     	     	
Annual Inc. %:	     	     		Annual Inc. %:	     	     	
Survivor %:	     	     		Survivor %:	     	     	

Social Security Income:

Individual 1:	Monthly Amount	Increase %		Individual 2:	Monthly Amount	Increase %	
Start Age:	     	     		Start Age:	     	     	
Monthly Benefit:	     	     		Monthly Benefit:	     	     	

Tax Information/Itemized Deductions

Enter your filing status and the number of exemptions that you claim.  Enter any tax deductions that you may have.  Estimate any of the annual amounts.  

Filing Status

 Single      Joint       Head of Household 

Number of Exemptions:  	     	

Itemized Deductions		
	Annual Amount	
Charitable Contributions	     	
Medical Expense (Not Premiums):	     	
Miscellaneous:	     	
Other Deductible Interest:	     	
Property Tax:	     	
Other Tax (Not Property):	     	

Life Insurance

Enter any life insurance policies that are in force.  Be sure to include any company insurance policies (Group or Term) in the Term amount. 

Individual 1				
	Amount	Annual Premium	Cash Value	
Permanent:	     	     	     	
Term:	     	     		

Individual 2				
	Amount	Annual Premium	Cash Value	
Permanent:	     	     	     	
Term:	     	     		

Other Insurance

This section covers any other insurance costs not paid through your employer.  If both individuals are covered under one policy only include the Annual Premium for one individual.  

Individual 1			
	Amount	Annual Premium	
Auto Insurance:	     	     	
Medical:	     	     	
Long Term Care:	     	     	
Homeowners:	     	     	
Disability:	     	     	

Individual 2			
	Amount	Annual Premium	
Auto Insurance:	     	     	
Medical:	     	     	
Long Term Care:	     	     	
Homeowners:	     	     	
Disability:	     	     	

Disability Coverage

Enter the short and long-term monthly benefits you would be eligible to receive should you become disabled.  These are monthly amounts paid to you. 

Individual 1			
	Short-Term Monthly Amount	Long-Term Monthly Amount	
Personal Coverage:	     	     	
Company Coverage:	     	     	

Individual 2			
	Short-Term Monthly Amount	Long-Term Monthly Amount	
Personal Coverage:	     	     	
Company Coverage:	     	     	

Personal Expenses

Enter any personal expenses in the following section.  This section should not include any payments from previous sections such as Loan or Mortgage payments, Insurance Premiums, or Itemized Deductions. 

	Monthly Amount	
Miscellaneous:**	     	
Clothing:	     	
Transportation:	     	
Utilities:	     	
Household:	     	
Children:	     	
Personal:	     	
Gifts / Vacations:	     	
Food:	     	

** Use Miscellaneous for a single amount entry covering all expenses. 

	Monthly Amount	
Pre-Retirement Inflation Rate:	     	
Post-Retirement Inflation Rates:	     	

Other Income/Expenses

Enter any other Income and Expense items in the next section.  For example, you could include the future purchases of a vehicle, an inheritance that you will receive, or vacation.  Be sure to use negative numbers for purchases or expenses, and positive number for income items.   

Single Year			
Name	Annual Amount	Start Age	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

Multiple Year				
Name	Annual Amount	Start Age	Stop Age