77 Access Road, Suite 6, Norwood, MA Tel (781) Fax (781) PERSONAL INFORMATION
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1 77 Access Road, Suite 6, Norwood, MA Tel (781) Fax (781) PERSONAL INFORMATION Name(s) Address Home Phone Home Fax Home Please check preferred location to receive correspondence: Home Address Home Business Address Business SELF SPOUSE/OTHER Date of Birth Social Security Number Occupation Employer Business Address Business Phone Business Fax Business Check if Retired Former Occupation Date Retired Last Employer Hobbies/Interests Wedding Anniversary CHILDREN Name Date of Birth Married? Grandchildren (ages)
2 ASSETS & LIABILITIES A. CURRENT ASSETS You may skip this section if you have provided your own balance sheet or copies of current account statements. PLEASE NOTE LOW COST BASIS FOR TAXABLE ACCOUNTS WHERE APPLICABLE. SELF SPOUSE/OTHER JOINT Cash/Savings/CDs Brokerage/Mgd Accts Separate Mutual Funds Separate Stocks Separate Bonds IRAs/SEP-IRAs Roth IRAs Rtmt Plans (401(k), 403(b)) _ Pension Plans Vested Stock Options Non-Vested Options Business Interest Home/Condo Other Real Estate Other B. LIABILITIES Description (Mortgage, Auto, Debt, etc.) Current Balance Mthly Pymt Interest Rate Payoff Date C. SCHEDULED SAVINGS, (MONTHLY AMOUNT) SELF SPOUSE/OTHER JOINT Savings/Investment IRA/Other Retirement Other Employer-Sponsored Retirement Plan Your Contribution Employer Contribution D. EXPECTED ASSETS I/We expect to receive the following gifts/inheritances/distributions: Current Value Date Expected Source/Comments 2 of 9
3 INCOME & EXPENSES CURRENT MONTHLY INCOME (GROSS) SELF Salary & Bonus Social Security Pension Rental Income Other SPOUSE/OTHER CURRENT ANNUAL EXPENSES FIXED DISCRETIONARY Federal & State Income Taxes Food Mortgage/Rent Alcohol, Tobacco Property Taxes Childcare Home Heating Education/Camp/Sports Utilities Pets Water Household Maintenance Telephone Domestic Help Cable Service Contributions/Donations Internet Service Transportation Garbage Collection Medical/Dental Care Installment Payments Clothing Auto Insurance Personal Care Medical & Dental Insurance Laundry/Dry Cleaning Homeowners/Renters Insurance Membership Dues Life Insurance Gifts Other Insurance Entertainment Other Vacation & Travel Auto Maintenance & Operation Newspapers/Periodicals/Books Other UNUSUAL (ONE-TIME) EXPENSES Description Year Amount 3 of 9
4 A. RETIREMENT My/Our retirement goals are the following: FINANCIAL GOALS Begin Self at Age Spouse/Other Begin at Age Desired retirement age OR year Desired retirement income (today s $) Expected lump sum pension benefit Expected monthly pension income Expected monthly Social Security income I/We expect our retirement living expenses to be % of today s expenses. B. EDUCATIONAL FUNDING I/We expect to assume the following educational costs: Year College Current Child/Grandchild Will Begin Today s Cost Amount Saved C. GIFTS & DONATIONS I/We would like to provide the following: Recipient Year Amount D. OTHER FINANCIAL GOALS Please describe additional goals: their expected cost and implementation date. (Acquire other assets, i.e. a vacation home; Support parents/children/relatives?) 4 of 9
5 A. LIFE INSURANCE I/We currently have the following policies in force: INSURANCE PLANNING Policy I Policy II Policy III Policy IV Insured Owner Beneficiary Type of Policy (Term, Whole Life, Universal) Face Amount Annual Premium Cash Value B. DISABILITY INSURANCE I/We currently have the following coverage: Monthly Benefit ER Paid Annual Insured Company Benefit Period Plan? (Y/N) Premium C. LONG TERM CARE INSURANCE Inflation Home Health Annual Insured Company Daily Benefit Protection % Care (Y/N) Premium D. HOMEOWNERS/RENTERS LIABILITY COVERAGE I/We currently have the following coverage: Company Coverage Amount Annual Premium E. AUTOMOBILE LIABILITY COVERAGE I/We currently have the following coverage: Company Coverage Amount Annual Premium F. UMBRELLA LIABILITY COVERAGE I/We currently have the following coverage: Company Coverage Amount Annual Premium 5 of 9
6 ESTATE PLANNING I/We would like to leave our beneficiaries and/or charities a total estate valued at $. (today s dollars) CURRENT ESTATE I/We currently have a: Document Yes No Date of Last Review Will Living Trust Health Care Power of Attorney Durable Power of Attorney Irrevocable Life Ins. Trust Funded Trust Generation Skipping Trust Other (Unified Credit, Marital, etc.) ESTATE PLANNING GOALS & NEEDS Would you like to/do you need to: Yes No Estimate & reduce estate taxes Consider life insurance to pay estate taxes Eliminate Probate if possible Organize orderly transfer of estate to beneficiaries Provide gifts to charity OTHER ESTATE PLANNING NEEDS OR CONCERNS 6 of 9
7 FINANCIAL PLANNING My/Our major concerns and objectives are as follows: Most Least Important Important N/A Early retirement Ensure comfortable retirement income Provide for family in event of death/disability Provide educational funds (children/grandchildren) Review & analyze insurance needs Review employer benefits (401(k), insurance, etc.) Review employer stock options Review & analyze cash flow (income vs. expenses) Improve tax planning & preparation Other Of the items ranked 1 and 2 above, please briefly describe your concerns and what assistance would be most helpful in order to obtain your goals. INVESTMENT MANAGEMENT Are you currently managing your own portfolio? Yes No How Long? Are you currently working with a Broker/Advisor? Yes No How Long? Please rate your current level of satisfaction with the performance of your existing portfolio: Very Satisfied Satisfied Not Satisfied My/Our major investment goals are to: Most Least Important Important Provide more growth to current portfolio Provide more income from current portfolio Reduce risk and volatility Other of 9
8 EXPERIENCE I/We have worked with the following professionals to date and would rate their services as follows: Excellent Good Average Poor No Exp Attorney Accountant Insurance Agent Stockbroker Trust Officer Other Bank Officer Financial Planner I was referred to Proficient Wealth Counselors, LLC by: (Please be specific listing source s full name) An attorney: An accountant: A newspaper article: A seminar: A realtor: A mortgage broker: A Proficient Wealth Counselors, LLC client: Other: Client Signature(s) and Date 8 of 9
9 FINANCIAL RECORDS If possible, please provide us with copies of the following financial records. These documents and the completed questionnaire will help us develop the most accurate and complete financial plan and will save time and questions later. Current account statements: Savings accounts Certificates of deposit Money market accounts Mutual funds Annuities Stock and/or Bond certificates Brokerage/Managed accounts IRAs, SEP-IRAs, Roth IRAs, etc. Employer stock option statement Retirement plans & list of investment options: 401(k), 403(b), etc. Life insurance policies (plus current premium invoice for cash surrender value) Social Security income estimates Wills/Trust documents Mortgage statement Other loan statements (including credit card debt) Income tax returns, federal and state (last 2 years if available) Employer Benefits handbook Employer contracts Recent payroll stub Other financial records 9 of 9
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