Confidential
Financial Planning
Questionnaire

Name	_____________________________		
Date	_____________________________		
Planner	_____________________________		

Personal Information

Scenario Title (Example “Financial Plan”)_________________________________________

Names to be shown on cover ___________________________________________________

Marital Status:  (check one)    _ _  Single  _ _  Married     Date Married:_________________

Names & Ages:	Individual 1	Individual 2	
First Name, Middle Initial			
Last Name			
Birth Date			
Retirement Age			
Life Expectancy Age			
Social Security Number			
Gender (Male/Female)			

Home Address:		
Address		
City, State, Zip		
	Individual 1	Individual 2	
Home Phone	(            )              - 	(            )              - 	
Work Phone	(            )              - 	(            )              - 	
Mobile Phone	(            )              - 	(            )              - 	
Email Address			
Web Page		

Employment:	Individual 1	Individual 2	
Duties/Title			
Employer			
Work Address			
City, State, Zip			
Work Phone	(            )              - 	(            )              - 	
Email			
Fax			

Asset Worksheet (Personal accounts – not in a retirement plan or IRA)

Instructions located on the "Asset and Retirement Account Worksheet Instructions" page.

Description	
Group	Liqu-idity	
Class	
Type	
Owner	Benefi-ciary	Current value	# of shares	$ per share	
Cost basis	Int/Div rate	Apprec rate	Used for

Retire-ment?	
							$			$	%	%		
							$			$	%	%		
							$			$	%	%		
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							$			$	%	%		

Retirement Account Worksheet  (Tax Deductible Retirement Accounts and Roth IRA)

Instructions located on the "Asset and Retirement Account Worksheet Instructions" page. 

Description	
Group	
Class	
Type	
Value	# of 
shares	$ per 
share	Int/div rate	Personal
additions	Company additions	Owner	
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
				$		$	%	$	$		
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				$		$	%	$	$		
				$		$	%	$	$		

Asset and Retirement Account Worksheet Instructions

Description 	Enter the description of the investment account.	

Group	Enter the investment group from one of the following choices:	
1.)  Annuity	11.)  Mutual Fund Balanced	21.)  Partnership – Equipment Lease	
2.)  Bonds – Corporate	12.)  Mutual Fund International	22.)  Partnership – Other	
3.) Bonds – International	13.)  Mutual Fund Real Estate	23.)  Partnership – Research & Development	
4.)  Bonds – Municipal	14.)  Mutual Fund Stock	24.)  Partnership – Real Estate	
5.)  Certificate of Deposit	15.)  Other Personal Assets	25.)  Real Estate/REIT	
6.)  Checking Account	16.)  Other Tax-Deferred/Free	26.)  Savings Account	
7.)  Collectibles (gold, silver, coins)	17.)  Other/Business	27.)  Stocks – International	
8.)  Ins. CV/SPWL/UnivLife	18.)  Personal Property	28.)   Stocks – Other Securities	
9.)  Money Market	19.)  Partnership – Cable TV		
10.)  Mortgages & Notes	20.)  Partnership – Energy		

Asset class  Enter the CLASS ID for each asset as identified below.
Class ID	Class name	Class ID		Class ID		
Res	Reserves					
Inc	Income					
Gr/Inc	Growth and Income					
Gr	Growth					
AgGr	Aggressive growth					
Misc	Misc.					

Asset worksheet:
Type	Enter the type of non-qualified plan from one of the following choices:	
1.) None	2.) Taxable 	3.) Equity/ Other 	4.) Tax Deferred	5.) Tax Free	

Retirement account worksheet:
Type	Enter the type of retirement plan from one of the following choices:	
1.)  457 Deferred Compensation	2.)  IRA Account	3.)  Keogh	4.) Other	5.)  401(k) Plans	6.) Profit Sharing	
7.)  Roth IRA	8.)  Roth 401(k)	9.) SAR / SEP	10.)  Simple (IRA or 401(k))	11.)  ISA /403b	

Current value	Enter the current value of the investment.	
# of shares	Enter the number of shares of the investment.	
$ per share	Enter the price per share of the investment.	
Cost basis (asset worksheet only)	Enter the original amount the individual paid for the investment.	
Interest/dividend rate	Enter the average annual interest/dividend rate of the investment. 	
Appreciation rate (asset worksheet only)	Enter the average annual appreciation rate of the investment.	

Monthly additions:
Personal additions	Enter the monthly additions to the asset account paid from personal funds.	
Company adds ( Retirement account worksheet only)	Enter the monthly company additions to the qualified accounts.	
Increase rate for monthly additions (rate adds)	Enter an increase rate for the monthly additions to the assets.	

Owner	Enter the account owner of the investment from one of the following choices:	
1.)  Individual 1	2.)  Individual 2	3.)  Irrev. Trust	4.)  Joint	5.)  Rev. Trust             (Ind. 1)	6.)  Rev. Trust (Ind. 2)	7.)  Rev. Trust (Joint)	

Personal Assets Worksheet

Description	Group	Value	Apprec. rate	Owner	Beneficiary		
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				
		$	%				

Instructions:
Description	Enter the description of the personal asset.  For example, Residence, Allen’s Car, Betty’s Ruby Ring.	
Group	Enter one of the following options:	
1.)  Art, Antiques	2.)  Automobiles	3.)  Boats, RV’s	
4.)  Jewelry, Furs	5.)  Personal Property	6.)  Residence	
Value	Enter the current dollar value of the asset.	
Appreciation rate	Enter the average expected appreciation (or depreciation) rate of the asset.	
Account owner	Enter the account owner of the asset from one of the following choices:	
1.)  Individual 1	2.)  Individual 2	3.)  Irrev. Trust	4.)  Joint	
5.)  Rev. Trust (Ind. 1)	6.)  Rev. Trust (Ind. 2)	7.)  Rev. Trust (Other)	7.)  Other	
Beneficiary	Enter the beneficiary of the asset from one of the following choices:	
1.)  N/A	2.)  Individual 1	3.)  Individual 2	4.)  Child 	5.)  Other	

 

Residence

	Residence #1	Residence #2	
Current Residence Market Value	$	$	
Original Cost + Improvements (Less Prior Deferred Gain)	$	$	
Appreciation Rate	%	%	

Sale of the Residence(s):	Residence #1	Residence #2	
Individual 1’s Age at Sale			
Sales Costs (Percent of Sale Price)	$	$	
Cost of Replacement Home to Finance	$	$	
New Mortgage (% of Replacement Home to Finance)	%	%	
Interest Rate on New Mortgage Loan	%	%	
Number of Years for the New Loan			

Instructions:
Current Market Value – enter the current value of the house(s). If more than one house, enter the second house in column #2.
Original Cost + Improvements – enter the original cost you paid for the house, plus the costs of improvements to the house since you purchased it.
Appreciation Rate – enter the anticipated appreciation rate on the house(s).
Individual 1’s Age at Sale – enter the Individual 1’s age, if you intend to purchase another house at a future age.
Sales Costs (Percent of Sale Price) – enter the sales costs as a percentage of the market value at the time of sale. For example, real estate broker commission or advertising costs. Generally 6% to 10%.
Cost of Replacement Home (Today’s dollars) – enter the estimated cost of the new house in today’s dollars.
New Mortgage (% of Replacement Home to Finance) – enter the new mortgage amount as a percentage of the price of the new house. For example, 80% - indicating a 20% down payment.
Interest Rate on New Mortgage Loan – enter the assumed interest rate of the mortgage loan on the new house. 
Number of Years for the New Loan – enter the number of years on the mortgage loan. For example, 15 or 30 years.

Objective and Resource Information

Risk Tolerance Level:  ____________________________

Choose one of the following risk levels:
1.	Very Conservative
2.	Conservative
3.	Moderate
4.	Aggressive
5.	Very Aggressive
Note:  If you are not sure of your risk tolerance level, fill out the following Risk Test.

Risk Test:

Check the boxes next to the statements that most accurately reflect your attitudes about investing.
ٱ	I am more concerned about protecting my assets than about growth.
ٱ	I prefer the ease of mutual funds to the uncertainty of trying to pick winning stocks.
ٱ	Professional advisors and mutual funds may achieve higher growth that I can.
ٱ	I am comfortable with investments that promise slow, long term appreciation and growth.
ٱ	I don’t brood over bad investment decisions I’ve made.
ٱ	I don’t like surprises.
ٱ	I am optimistic about my financial future.
ٱ	My immediate concern is for income rather than opportunities.
ٱ	I am a risk taker.
ٱ	I make investment decisions comfortably and quickly.
ٱ	I like predictability and routine in my daily life.
ٱ	I usually pick the tried and true, the slow, safe but sure investments.
ٱ	I need to focus my investment efforts on reserve funds and insurance rather than growth.
ٱ	I prefer predictable, steady returns on my investments even if the return is low.

Financial Objectives:
	<<Low                       High>>		
Reducing income taxes	O      O      O      O      O         		
Protection from inflation	O      O      O      O      O         		
Maximum investment growth potential	O      O      O      O      O         		
Current spendable income from assets	O      O      O      O      O         		
Liquidity (convert assets to cash)	O      O      O      O      O         		

Note:  Place a mark in the circle closely representing the financial objective for each of the above statements.

Dependent Children 

Children & Ages:
First, middle Initial, last name	Social Security number	Birth date	Dependent until age		

					

					

Education:

Percent of college costs parents plan to pay.	____________%		
Inflation rate for education expenses.	____________%		
Rate of return, after tax of education funds.	____________%		
Check to deduct education expenses from retirement funds.	_ _		

Child’s name	1st year of college	# of years	School type	Funds 
available now	Annual college cost	Monthly savings		
				$	$	$		
				$	$	$		
				$	$	$		
				$	$	$		
				$	$	$		
				$	$	$		
				$	$	$		

For All Children:

Percent of college costs parents plan to pay.	____________%		
Inflation rate for education expenses.	____________%		
Rate of return, after tax of education funds.	____________%		
Check to deduct education expenses from retirement funds.	_ _		

Instructions:
1st year of college	Enter the calendar year the child will begin college.	
School type	Select the type of school from one of these chooses:  1.) Public   2.) Private	
# of years	Enter the number of years the child will be attending college.	
Annual college cost	Enter the amount of the annual college costs in today’s dollars.	
Funds available now		Enter the present value of the funds available now for college.	
Monthly savings	Enter the monthly savings amount to be entered into the college fund.	
Earned Income (Annually):
 	Age	Tax report	Increase rate	Cash flow report	Disability report	Survivor report	
 Individual 1 Salary and Wages:	 	 $	            %	 $	 $	 $	

							
							
 Individual 2 Salary and Wages:	 	 $	            %	 $	 $	 $	

							
							
 Individual 1 Self-Employment:	 	 $	            %	 $	 $	 $	

							
							
 Individual 2 Self-Employment:	 	 $	            %	 $	 $	 $	

							

Instructions:
Age: enter in the first row the current age. If the salary amount will change at a future age, then enter that age in the next row.  If there will be additional changes in future years, continue to enter the new age on the next line.
Increase rate: enter in the first row the current increase rate to be used on the salary amount. If the salary amount changes, but the increase rate stays the same, enter the same increase rate. If the rate of increase will change up or down in a later year, then enter the new increase rate at the appropriate age.
Tax report: Amounts in this column will be used on the Income Tax report.  This may be the same or different than the amounts used in the Cash Flow, Disability, or Survivor reports.
Cash flow report: Amounts entered here will be shown as available to spend in the Cash Flow report.  These amounts may be different than the amounts shown in the Tax Report column.  For example, if interest and/or dividends are being reinvested, you may NOT want show these amounts as available in the Cash Flow Report column.
Disability report: Represents income available in the event of disability.  Individual 1’s salary will be available if Individual 2 is disabled.   Individual 2’s salary would be available if Individual 1 is disabled.
Survivor report: Amounts entered here represent income available in a survivor situation.  The amount of Individual 1’s salary if Individual 1survives Individual 2.   Individual 2’s salary would be available if Individual 2 is the survivor.  
Retirement Social Security Benefits (Monthly):
	Individual 1	Individual 2		
Are you qualified to receive SS benefits? (Yes/No)				
Age to start retirement SS benefits (62-70)				
Percent of computed SS benefits to show on report	%	%		
Actual amount of expected SS benefits (today’s $ / month)	$	$		
Social Security benefit increase rate (SS COLA)	%	%		

Instructions:
Percent of benefits to show: If your SS benefits will be less than might be expected based on your current earnings, the report will use a reduced benefit amount. Make a note here to indicate that the benefits might be reduced.
Actual amount expected: If you have your Social Security statement you may enter the benefit amount shown on the statement here. This amount will override any calculated estimate.
SS benefit increase rate: Enter the assumed rate that you think the SS benefits will increase, or leave blank and your advisor will provide a default estimate.

Survivor Social Security Benefits (Monthly):
	Individual 1	Individual 2		
Actual/Estimated benefit with 2 or more children at home	$	$		
Actual/Estimated benefit with 1 child at home	$	$		
Actual/Estimated Survivor retirement benefit	$	$		
Age to start survivor SS benefits (60+)				

Instructions:
Survivor SS benefits: This section is used only if you are currently receiving SS survivor benefits or if you believe the survivor benefit you might receive will be different that a computed amount based on the earned income for the deceased spouse. In most cases this section may be ignored.

Pension (Monthly Amounts): 

Pension plan	Age	Monthly benefit	Increase rate	Increase amount					
 Individual 1 Pension 1 

 Name: _________________	 	 $	                %	 $	 Pension State Tax Exempt?   Yes  __ No __ 

 Survivor benefit % _______                        

 Survivor $/mo prior to pension start ______	

	 					
 Individual 1 Pension 2 

 Name: _________________	 	 $	                %	 $	 Pension State Tax Exempt?   Yes  __ No __ 

 Survivor benefit % _______                        

 Survivor $/mo prior to pension start ______	

	 					
 Individual 2 Pension 1 

 Name: _________________	 	 $	                %	 $	 Pension State Tax Exempt?   Yes  __ No __ 

 Survivor benefit % _______                        

 Survivor $/mo prior to pension start ______	

	 					
 Individual 2 Pension 2 

 Name: _________________	 	 $	                %	 $	 Pension State Tax Exempt?   Yes  __ No __ 

 Survivor benefit % _______                        

 Survivor $/mo prior to pension start ______	

	 					

Instructions:
Name – Individual 1 and 2 can each enter two pension plans. 
Age – enter in the first row the age when the pension will start.  If the pension amount will change in the future, enter the age when the change will occur in the next row.  
Pension amount per year – enter in the first row the current pension amount. If the pension amount will change at a future age, then enter that new pension amount in the row directory below the current pension amount. If the pension amount will have additional changes in future years, continue to enter the new pension amounts at the new age. If the pension will continue until life expectancy (with only inflation increases) leave the additional lines blank.
Increase rate (inflation rate) – enter in the first row the current increase rate to be used on the pension amount. If the pension amount changes, but the increase (inflation) rate stays the same, enter the same increase rate in the first and second row. If the increase will change at any age, enter the new increase rate on the appropriate row.
Increase amount – if the pension is going to increase a specific dollar amount, enter the dollar amount that the monthly benefit increases each year. 

Other Income and Expenses:
			Amount for survivor report	
Description	Start age	Stop age	Amount for retirement report	Percent increase	Individual 1	Individual 2	Percent taxable	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	
			$	%	$	$	%	

Instructions:
Note:  Other income or expense items can occur in a single year, such as an inheritance or extended vacation or multiple years, such as an annuity or trust income, deferred compensation income for x years, a planned gifting program covering multiple years, etc.
Description:  Enter a description of the income or expense.
Age:  Enter age(s) when the income or expense will occur (start/stop age). All ages are based on individual 1.
Retirement amount:  Enter the amount of the income or expense that should be shown on the retirement report.  Enter a positive amount for an income and a negative amount for an expense.  An amount in this column will be added or deducted from the retirement capital, adjusted for taxes and inflation (percent increase rate).
Percent increase:  Enter the percentage rate that you expect the income or expense will be increasing.
Amount for survivor (Individual 1 and Individual 2):  If the income or expense item should be considered in the Survivor reports, enter the amount of the income or expense in the appropriate column. This income or expense amount, adjusted for the increase rate and taxes, will be displayed on the Survivor report page and a different amount may be used than the amount shown for the retirement report. Enter a positive amount for income, negative for expense.
Percent taxable: If an income amount will be treated as taxable income, enter the portion taxable. The amount shown in the reports will be reduced by the estimated income tax due on the item.
Income Tax Data

Tax Data (Annual amounts):	Age	Tax report	Cash flow report	Disability report	
 Schedule D Capital Gain or (Loss)	 	 $	 $	 $	

 Schedule E Passive Gain or (Loss)	 	 $	 $	 $	

 Federal Taxable Income or (Loss)	 	 $	 $	 $	

 Other Federal Tax or (Credit)	 	 $	 $	 $	

 State Taxable Income or (Loss)	 	 $	 $	 $	

 Other State Tax or (Credit)	 	 $	 $	 $	

 AMT preference items	 	 $	 $	 $	

 Other Taxable Income or (Loss)	 	 $	 $	 $	

 Other Non-Taxable Income or (Loss)	 	 $	 $	 $	

Instructions:
Tax report   Enter taxable amounts for each category.  Amounts in this column will be used on the Income Tax report.  This may be the same or different than the amounts used in the Cash Flow, Disability, or Retirement reports.
Cash flow report   Amounts entered here will be shown as available to spend in the Cash Flow report.  These amounts may be different than the amounts shown in the Tax Report column. For example, if interest and/or dividends are being reinvested, you may NOT want show these amounts as available in the Cash Flow Report column.
Disability report   Represents income available in the event of disability.  Individual 1’s salary will be available if Individual 2 is disabled.  Individual 2’s salary would be available if Individual 1 is disabled.
Increase (decrease) federal / State taxable income: If it is anticipated that the amount of taxable income you will report will be greater or less than the sum of the earned income, interest, etc. shown above, enter an amount (positive or negative) to be used to increase or decrease the calculated income. For example, if you have “phantom income” from a partnership or an amount that will need to be included because of an audit of a prior year tax return.
Other Federal / State tax or credit: If you will have additional taxes or credits (not including the amounts calculated from the above information), enter the estimated amounts here.
AMT preference items: If you have AMT preference income to report (other than that calculated from the data above) enter an estimated amount here.
Filling Status Options:

Tax Filing Status  (Check one)	Single: ______	Married: ______	Head of Household: ______	
Number of regular exemptions	________________	
Number of individuals over age 64 or blind	________________	

Other Adjustments (Golden Years Only):

Self employment medical insurance premiums (total amount)	$ ________________	% ________	
Alimony – Payable to Age ______	Amount/Increase Rate	$ ________________	% ________	

Itemized Deductions:	Age	Percent of gross income	and/or	Dollar amount	Annual rate of increase	
 Charitable Contributions:	 	                          %  	and/or	 $	                          %  	

 Medical Expenses:	 	                          %  	and/or	 $	                          %  	

 Miscellaneous:	 	                          %  	and/or	 $	                          %  	

 Other Deductible Interest:	 	                          %  	and/or	 $	                          %  	

 Other Tax:	 	                          %  	and/or	 $	                          %  	
 (Non Property or State tax)	 					
 	 					
 Property Tax:	 	                          %  	and/or	 $	                          %  	

Instructions:
Itemized deductions   Enter either a percentage of gross income and/or a dollar amount for all the itemized deductions for the current age and any future ages. If both are entered, the report will combine the amounts on the tax report. Enter an annual percentage increase rate if the deduction amount will increase each year.  An example of an Other Tax (Not Property or State) could be an Annual Auto License Tax for some states.
Percent of gross income:  A percent entered in this column will be used to compute a deduction based on your gross income for the year.  For example, if you enter 3% in this column for medical expenses and your gross income is $40,000 annually then we will compute your medical expenses at $1,200.
Dollar amount / increase rate: Use this column to indicate specific dollar amounts and increase rates. For example if you give $500 each year to the Boy Scouts with no increases anticipated enter $500 / 0% in the charitable row. If you have miscellaneous deductions of about $2,000 and they increase at 3% per year, enter $2,000 / 3.0%
Property tax: This row asks for the property tax stated as a percent of the property value, not gross income. You may divide the property tax by the market value of the home to determine this rate.

Liabilities 

Description	
Type	Owed to	Owned by	Date opened	Original amount	Account balance	Monthly payment	
Interest	Payoff?	Balloon pymt age	
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			
					$	$	$	%			

Instructions:		
Description	Describe the liability.  For example, Home Equity Loan, Betty’s Car Loan, School Loan, etc.	
Type	Enter the liability type from the following choices:	
     1.)  Residence Mortgage (Home 1)	4.)  Auto Loans	7.)  Other Liabilities	
     2.)  Residence Mortgage (Home 2)	5.)  Credit Cards	8.)  Investment Real Estate	
     3.)  Investment Loans	6.)  Personal Loans	9.)  RV and Boat Loans	
Owed to	Name of the person or company the liability is owed to.	
Owned by	Enter person who owes the liability from one of the following choices:	
     1.)  Child	2.)  Individual 1	3.)  Individual 2	4.)  Joint	
     5.)  Community Property	6.)  Irrevocable Trust	7.)  Other		
Date opened	Enter the date when the loan was opened.	
Original amount	Enter the original amount of the liability.	
Account balance	Enter the current account balance of the liability.	
Monthly payment 	(Principal & interest only)    Enter the monthly payment of the liability.*	
Interest	Enter the interest rate on the liability.	
Payoff?	Indicate if you want the liability to be paid off at death from one of the following choices:	
       1.)  No	2.)  Both Deaths	3.)  Individual 1’s Death Only	4.)  Individual 2’s Death Only	
Balloon payment age	Enter the age a balloon payment will occur. 	
* If you are making additional principal payments along with your regular principal and interest, you may enter the total of the payment, not including insurance and taxes.
Insurance Information 

Term/Group Life Insurance Policies:
Description	

Company name	
Insured	Beneficiary	Owner	Policy number	Annual premium amount	Policy face amount	
						$	$	
						$	$	
						$	$	
						$	$	
						$	$	
						$	$	

Permanent Life Insurance Policies:
Description / company	Insured	Benef.	Owner	Policy number	Current loan	Period	Annual premium	Policy face value	Cash value	
 	 	 	 	 	 
 $	 Now	 $	 $	 $	
						 Retirement	 $	 $	 $	
 	 	 	 	 	 
 $	 Now	 $	 $	 $	
						 Retirement	 $	 $	 $	
 	 	 	 	 	 
 $	 Now	 $	 $	 $	
						 Retirement	 $	 $	 $	
 	 	 	 	 	
 $	 Now	 $	 $	 $	
						 Retirement	 $	 $	 $	
 	 	 	 	 	
 $	 Now	 $	 $	 $	
						 Retirement	 $	 $	 $	

 Instructions:
Company name   Enter the name of the company carrying the insurance.  For example, Lincoln National.  
Description   Enter a description of this type of policy.  For example, Protection Plus.
Insured   This field represents the person insured by the policy.  Two choices:  Individual 1 or Individual 2.
Annual premium amount   Enter the annual premium amount for the policy.  
Policy face amount   Current amount of insurance that will be paid upon the death of the insured.  
Cash value now   Enter the full amount of cash value here.  You can generally get the amount from the policy table of values.  If the value is not shown at the current age or you do not have the actual policy, then you may need to estimate the value now.  Do not deduct any loans against the policy.
Cash value at age 65   Used in the retirement projections to determine cash available.  If an individual retires substantially earlier than age 65, enter the amount of cash value at the individual’s retirement age (or an estimate of the cash value.)
Present loan amount   Enter the dollar amount borrowed against this policy. 

Miscellaneous Insurance Premiums:

	Age	Individual 1	Age	Individual 2	
Auto Insurance Premiums:	 		 		

Disability Insurance Premiums:	 		 		

Long Term Care Insurance Premiums:

	 		 		
Medical Insurance Premiums:

	 		 		
Homeowners, Property & Casualty, Other Premiums:	 		 		

Disability / Long Term Care Insurance:
	Individual 1	Individual 2	
Disability Insurance Monthly Benefit – Short Term	$	$	
Disability Insurance Monthly Benefit – Long Term	$	$	
Company Disability Benefits per Month – Short Term	$	$	
Company Disability Benefits per Month – Long Term	$	$	
Percent of Company Benefits that are Taxable (0-100%)	%	%	
Do you have Long Term Care Insurance  (Yes/No)			

Proposed Long Term Care (LTC):*

Premium Per Year	$	
Benefits Per Day	$	
Benefits Payable to Age	$	
Cost Per Month	$	
Number of Months of Care		
*This LTC section is for use by your financial advisor.

 Personal Expenses
				         Current amount		   Percent to be used for:
	Monthly*	Annual		Retirement	Disability	Survivor	
Rent/lease Payment (not mortgage)							
Food and household incidentals							
        Groceries							
        Household Supplies							
        Eating Out 							
Utilities, Telephone							
        Gas / Electric							
         Water / Trash							
         Phone 							
Auto operating and maintenance							
        Gas / Oil							
        Repair							
        Parking Tolls							
Child Expenses							
        School Expenses							
        Lunch Money							
        Special Events							
        Baby Sit / Day Care							
Gifts / Birthday							
Holidays							
Domestic Help							
Clothing							
Laundry / Cleaning							
Property Improvements & Upkeep							
Home Furnishings							
Childs Support							
Alimony							
Entertainment							
Vacations							
Hobbies							
Memberships / Dues							
Pet Expenses							
Books / Subscriptions							
Cable TV							
Supplies							
Miscellaneous							

*Monthly/Annual – you may enter a monthly amount, annual amount, or both amounts.  For example, if your auto operating expenses average $150 per month, but you expect to spend another $500 per year in repairs, you would enter the $150 in the “Monthly” column and the $500 in the “Annual” column.
Percentage of expenses used for:  Retirement, Disability, and Survivor percentages – if the monthly expense amounts will be different in these three categories, then enter the percentage difference amount here.  For example, if all expense amounts will decrease by 20% then enter 80% in the appropriate column(s).
Note:  If you don’t want to fill out the personal expense items above, enter a lump sum amount in the Income Needed per Month in the “Miscellaneous” row. Do NOT include insurance premiums, taxes or debt payments. These will be gathered from other areas.

Financial Goals
(Specific items where you wish to compute the amount of immediate capital needed or the monthly deposits needed to fund a future expense.)

Description	Year needed	Amount needed	Inflation rate	

		$	%	
		$	%	
		$	%	
		$	%	

Anticipated rate of return on funds accumulated for goals:  ________________%
Include Financial Goals in Retirement Capital Estimate report:  _____________  (Yes/No)
 Stock Options – ISO/NQSO

Company Information:

Company name	Current market
value per share	
As of date	Anticipated appreciation rate	
	$		%	
	$		%	
	$		%	

Grant Information:
Company Name	Type*	Grant date	# of shares	Grant
(strike price)	Vesting date	Exercise date**	Exercise
method	Sale
date	
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					
				$					

*Type options:  1.)  ISO (Incentive Stock Option)    2.)  NQSO (Non-Qualified Stock Option)
**Exercise methods:  Upon exercise of the option, is it your intention to  1.)  Hold all shares    2.)  Sell part (to pay for the cost of exercise)     3.)  Sell all shares 

Survivor Information

Immediate Survivor Cash Needs:
	Individual 1	Individual 2	
Final expenses (burial, medical, etc.)	$	$	
Emergency funds, reserves	$	$	
Other Survivor cash needed (charitable gift, etc.)	$	$	

Should the “Other Survivor cash needed” shown above be included as a reduction to the estate assets on the Estate tax report?   __Yes   __No

Capital Consumption / Retention Option (Survivor and Retirement):
	Individual 1	Individual 2	
Amount of capital to be retained at life expectancy	$	$	
If you wish to have a specific amount of capital left to your ultimate heirs, enter the amount above. Otherwise the survivor capital needed will be computed with the assumption that all capital will be consumed by life expectancy.

Tax Rate on Survivor Earned Income:
	Individual 1	Individual 2	
Tax rate on earned income 	%	%	

Estate

Estate Assumptions:

Check the box if you have any of the following:	       Individual 1   Individual 2

Will  								_ _   		_ _  	

Revocable Living Trust					_ _   		_ _  	

Martial Trust Provisions					_ _   		_ _  	

Credit Shelter Trust Provisions				_ _   		_ _  	

Qtip Trust Provisions 						_ _   		_ _  	

Irrevocable Life Insurance Trust				_ _   		_ _  	

Durable General Power of Attorney				_ _   		_ _  	

Living Will							_ _   		_ _  	

Generation Skip Trust Provisions				_ _   		_ _  	

Joint Revocable Trust						_ _  		_ _  	

Testamentary Trust						_ _   		_ _