FINANCIAL MANAGEMENT QUESTIONNAIRE

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Imogene Paul
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1 FINANCIAL MANAGEMENT QUESTIONNAIRE This information will be used to prepare an individual report assessing your current financial needs. Your responses will not be sold or shared with any unaffiliated parties. STEP #1 Please complete the following forms, including as much information as possible. Please complete only the items that apply to your situation. STEP #2 Using the following check-list, include copies of all documents: Business documents (buy/sell agreements, approximate business value) Children s assets or UGMAs (most recent statements) Copies of Current Driver s license(s) Copy of Monthly Budget Employee benefits booklets Financial statement (most recent statements) Insurance policies (life, health, disability, long-term care, etc.) K-1s for limited partnership interests Loan Information (auto, credit card and lines of credit most recent statements) Mortgage information for home, property & business Recent Pay stub Retirement Plans (pension, IRAs, KEOGH, 401(k)) Statements for invested money* (most recent statements of: Stocks, bonds, mutual funds, limited partnership *Please include the cost basis for each investment the cost basis is necessary to determine the value of your investment. Tax returns - last two years, Federal and State (personal, corporation, partnership) Trust agreements Wills Social Security Statement (You can create a profile and print a copy at STEP #3 Return to: Mowatt Financial Inc. 383 Inverness Parkway, Suite 400 Englewood, CO If you have any questions, please do not hesitate to contact our office at dave@mowattfinancial.com Twineagles Blvd. Naples, FL Registered Principal offering securities and advisory services through Independent Financial Group, LLC (IFG), A Registered Broker/Dealer, Member: FINRA/SIPC. Mowatt Financial and IFG are unaffiliated entities.

2 No Plan Will Be Completed Without the Information Listed On This Page * CLIENT FIRST NAME M.I. LAST NAME NICKNAME HOME PHONE ( ) - HOME FAX ( ) - CELL PHONE ( ) - M/F ADDRESS CITY ST ZIP CODE DATE OF BIRTH / MARITAL STATUS DRIVER S LICENSE ATTACH COPY CITIZENSHIP PREFERRED MAILING ADDRESS: HOME WORK P.O.BOX EMPLOYER/OCCUPATION / MOTHER S MAIDEN NAME SPOUSE FIRST NAME M.I. LAST NAME NICKNAME HOME PHONE ( ) - HOME FAX ( ) - CELL PHONE ( ) - M/F ADDRESS CITY ST ZIP CODE DATE OF BIRTH / MARITAL STATUS DRIVER S LICENSE ATTACH COPY CITIZENSHIP PREFERRED MAILING ADDRESS: HOME WORK P.O.BOX EMPLOYER/OCCUPATION / MOTHER S MAIDEN NAME DEPENDANTS FIRST NAME Date of Birth CURRENT ASSETS FIRST NAME Date of Birth CURRENT ASSETS / / / / M.I. LAST NAME M/F M.I. LAST NAME M/F PLAN FILING STATUS TAX BRACKET MONTHLY RETIREMENT NEEDS $ INFORMATION CLIENT S DESIRED RETIREMENT AGE SPOUSE DESIRED RETIREMENT AGE DO YOU EXPECT TO GET THE MAXIMUM SOCIAL SECURITY? YES/NO ARE YOU A DEFENDANT IN ANY LAWSUIT? DO YOU HAVE ANY PAST BANKRUPTCY? YES/NO YES/NO IMPORTANT INDIVIDUALS Accountant, Attorney, Executor of Wills, Children s Guardian NAME OF ACCOUNTANT NAME OF ATTORNEY FIRM FIRM NAME OF EXECUTOR OF WILLS NAME OF CHILDREN S GUARDIAN FIRM

3 GOALS & OBJECTIVES OBJECTIVE: (CHOOSE ONLY ONE): INCOME GROWTH TOTAL RETURN INVESTMENT EXPERIENCE (YEARS): TOLERANCE: (CHOOSE ONLY ONE) EQUITIES DIRECT PARTICIPATION PROGRAMS CONSERVATIVE FIXED INCOME REITS MODERATE OPTIONS ANNUITIES AGGRESSIVE MUTUAL FUNDS REAL ESTATE INCOME INFORMATION SOURCE SALARY/BONUS/DIVIDEND AMOUNT BANK / CASH ASSETS Savings, Checking, Certificates Of Deposit, Money Markets BANK CURRENT BALANCE DATE OPENED TYPE OF ACCOUNT CHECK SAVINGS MONEY MARKET CD OTHER OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER ACCUMULATE FOR RETIREMENT FUNDING? YES/NO BANK CURRENT BALANCE TYPE OF ACCOUNT OWNERSHIP DATE OPENED CHECK SAVINGS MONEY MARKET CD OTHER CLIENT SPOUSE JOINT CHILD OTHER ACCUMULATE FOR RETIREMENT FUNDING? YES/NO BANK CURRENT BALANCE TYPE OF ACCOUNT OWNERSHIP DATE OPENED CHECK SAVINGS MONEY MARKET CD OTHER CLIENT SPOUSE JOINT CHILD OTHER ACCUMULATE FOR RETIREMENT FUNDING? YES/NO BANK CURRENT BALANCE TYPE OF ACCOUNT OWNERSHIP DATE OPENED CHECK SAVINGS MONEY MARKET CD OTHER CLIENT SPOUSE JOINT CHILD OTHER ACCUMULATE FOR RETIREMENT FUNDING? YES/NO SECURITIES INFORMATION Stocks, Mutual Funds, Bonds / FIRM ACCOUNT TYPE ACCOUNT NUMBER OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER STATEMENT ATTACHED / FIRM ACCOUNT TYPE ACCOUNT NUMBER OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER STATEMENT ATTACHED / FIRM ACCOUNT TYPE ACCOUNT NUMBER OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER STATEMENT ATTACHED / FIRM ACCOUNT TYPE ACCOUNT NUMBER OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER STATEMENT ATTACHED

4 REAL ESTATE ADDRESS TYPE RESIDENCE VACATION INVESTMENT OTHER CURRENT VALUE INTEREST RATE PAYMENT AMOUNT MORTGAGE BALANCE PURCHASE COST PURCHASE DATE ORIGINAL LOAN PERIOD/ LOAN TYPE ADDRESS TYPE RESIDENCE VACATION INVESTMENT OTHER CURRENT VALUE INTEREST RATE PAYMENT AMOUNT MORTGAGE BALANCE PURCHASE COST PURCHASE DATE ORIGINAL LOAN PERIOD/ LOAN TYPE ADDRESS TYPE RESIDENCE VACATION INVESTMENT OTHER CURRENT VALUE INTEREST RATE PAYMENT AMOUNT MORTGAGE BALANCE PURCHASE COST PURCHASE DATE LIMITED PARTNERSHIP/ BUSINESS INTERESTS OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER ACCUMULATE FOR RETIREMENT FUNDING? YES/NO UNITS PURCHASED PURCHASE DATE CURRENT VALUE COST/UNIT OWNERSHIP CLIENT SPOUSE JOINT CHILD OTHER ACCUMULATE FOR RETIREMENT FUNDING? YES/NO UNITS PURCHASED PURCHASE DATE CURRENT VALUE COST/UNIT LIFE IN THE EVENT OF YOUR DEATH, WHAT IS THE TOTAL MONTHLY INCOME NEEDED FOR YOUR FAMILY? IN THE EVENT OF YOUR SPOUSE S DEATH, WHAT IS THE TOTAL MONTHLY INCOME NEEDED FOR YOUR FAMILY? INSURED BENEFICIARY POLICY DATE CASH VALUE FACE VALUE PREMIUM AMOUNT PAYMENT INTERVAL LOAN AMOUNT INSURED BENEFICIARY POLICY DATE CASH VALUE FACE VALUE PREMIUM AMOUNT PAYMENT INTERVAL LOAN AMOUNT INSURED BENEFICIARY POLICY DATE CASH VALUE FACE VALUE PREMIUM AMOUNT PAYMENT INTERVAL LOAN AMOUNT INSURED BENEFICIARY POLICY DATE CASH VALUE FACE VALUE PREMIUM AMOUNT PAYMENT INTERVAL LOAN AMOUNT *PLEASE PROVIDE IN THE EVENT OF A TOTAL COPY DISABILITY, OF ALL WHAT CURRENT WOULD YOUR MONTHLY POLICIES, INCOME NEEDS ALONG BE? WITH A CURRENT STATEMENT

5 DISABILITY INSURED OWNER PAYOR WAITING PERIOD EFFECTIVE DATE PREMIUM AMOUNT MONTHLY BENEFIT INSURED OWNER PAYOR WAITING PERIOD EFFECTIVE DATE PREMIUM AMOUNT MONTHLY BENEFIT HEALTH COVERAGE $ PERCENTAGE PREMIUM AMOUNT DEPENDENT COVERAGE DENTAL COVERAGE VISION COVERAGE COVERAGE $ PERCENTAGE PREMIUM AMOUNT DEPENDANT COVERAGE DENTAL COVERAGE VISION COVERAGE LONG TERM CARE GROUP INDIVIDUAL OTHER EFFECTIVE DATE PREMIUM DATE PREMIUM AMOUNT DEPENDANT AMOUNT PER PERSON LIMIT GROUP INDIVIDUAL OTHER EFFECTIVE DATE PREMIUM DATE PREMIUM AMOUNT DEPENDANT AMOUNT PER PERSON LIMIT ALL ADDITIONAL INFORMAITON *PLEASE PROVIDE A COPY OF ALL CURRENT POLICIES, ALONG WITH A CURRENT STATEMENT

6 PENSION & RETIREMENT PLANS TYPE 401K PSP KEOGH IRA SEP PENSION MILITARY OTHER OWNERSHIP CLIENT SPOUSE OTHER BASE COST PURCHASE DATE VALUE DATE/AGE AVAILABLE HOW ARE BENEFITS RECEIVED? MONTHLY ANNUALLY LUMP SUM OTHER INFORMATION TYPE 401K PSP KEOGH IRA SEP PENSION MILITARY OTHER OWNERSHIP CLIENT SPOUSE OTHER BASE COST PURCHASE DATE VALUE DATE/AGE AVAILABLE HOW ARE BENEFITS RECEIVED? MONTHLY ANNUALLY LUMP SUM OTHER INFORMATION TYPE 401K PSP KEOGH IRA SEP PENSION MILITARY OTHER OWNERSHIP CLIENT SPOUSE OTHER BASE COST PURCHASE DATE VALUE DATE/AGE AVAILABLE HOW ARE BENEFITS RECEIVED? MONTHLY ANNUALLY LUMP SUM OTHER INFORMATION BUSINESS / MISC. NOTES PAYABLE TO CLIENT NAME ON NOTE: DATE NOTE WAS ISSUED: DATE NOTE DUE: NOTE PAYMENT: PER MONTH PER QUARTER PER YEAR NOTE INTEREST: LENGTH OF TERM: PRINCIPLE BALANCE: VEHICLES MAKE MODEL YEAR PURCHASE DATE PURCHASE COST MONTHLY PAYMENT AMOUNT TOTAL BALANCE OWED ON VEHICLE CURRENT VALUE MAKE MODEL YEAR PURCHASE DATE PURCHASE COST MONTHLY PAYMENT AMOUNT TOTAL BALANCE OWED ON VEHICLE CURRENT VALUE MAKE MODEL YEAR PURCHASE DATE PURCHASE COST MONTHLY PAYMENT AMOUNT TOTAL BALANCE OWED ON VEHICLE CURRENT VALUE OTHER INFORMATION *Please list any credit cards, lines of credit, and 401(k) loans and the current balances below:

7 Monthly Budget Worksheet Complete worksheet using your last month's activity CLIENT NAME: Income Spouse Income Additional Income Household monthly Income total: HOUSING Monthly Amount ENTERTAINMENT Monthly Amount Mortgage or rent Video/DVD Phone CDs Electricity Movies Gas Concerts Water and sewer Sporting events Cable Live theater Waste removal Maintenance or repairs Supplies LOANS Monthly Amount TRANSPORTATION Monthly Amount Personal Vehicle payment Student Bus/taxi fare Credit card Insurance Credit card Licensing Credit card Fuel Maintenance TAXES Monthly Amount Federal Monthly Amount State Home Health Life Local SAVINGS OR INVESTMENTS FOOD Monthly Amount Retirement account Groceries Investment account Dining out Monthly Amount

8 PETS Monthly Amount GIFTS AND DONATIONS Monthly Amount Food Charity 1 Medical Charity 2 Grooming Charity 3 Toys LEGAL Monthly Amount Attorney PERSONAL CARE Monthly Amount Alimony Medical Hair/nails Clothing Dry cleaning Payments on lien or judgment Health club OTHER (MISC) Monthly Amount Organization dues or fees TOTAL MONTHLY EXPENSES: TOTAL BALANCE: (income minus expenses)

The Wise Wealth Planning Workshop Questionnaire

The Wise Wealth Planning Workshop Questionnaire The Wise Wealth Planning Program Instructions After completion of form, click the submit button to e-mail data to Savant or print off a copy and mail it