Date: Information First Name Last Name Date of Birth Gender Retirement Age Marital Status Marital Date Citizenship Address Province Phone Number Will (Yes/No) Date of Last Will Power of Attorney (Yes/No) Employment Status Business Address Occupation Company Family Members Family Members Relationship First Name Last Name Date of Birth Citizenship Residency Dependent 1 Dependent 2 Dependent 3 Dependent 4 Tax Free Savings Account (TFSA) Historical Data As of end of previous year. TFSA Overcontribution Balance Unused TFSA Contribution Room Net Income for RESP Prior year. To determine Learning Bond availability. RESP Historical Data As of end of previous Prior year. RESP Subscribers net income last year (line 236 of tax return) Child 1 Child 2 Total RESP Contributions from All Subscribers CESG eligibility carry forward Total CESG Payment Received Child 3 RRSP Historical Data Refer to CRA Notice of Assessment. From N.O.A. Prior Year s Earned Income Prior Year s Pension Adjustment RRSP Overcontribution Balance Unused RRSP Deduction Limit (not RRSP room) Hassan Wealth Advisory Group 1
Lifestyle Assets e.g., residence, cottage, personal use property,personal listed property, etc. Market Value Purchase Amount /Adjusted Cost Base (ACB) Liabilities Balance Interest Rate Mortgage Line of Credit Personal Loans Debt Accounts Accounts Payment Amount/ Frequency Payment Type (principal & interest, interest only etc.) Account Type Owner Market Value Cost Base Rate of Return Pre-Retirement Retirement Savings Account 1 Account 2 Account 3 Account 4 Account 5 Account 6 Account 7 Account 8 Amount/ % of salary Period Goal (Retirement, Major Purchase, Education) Account Type Owner Market Value Cost Base Rate of Return Pre-Retirement Retirement Savings Account 9 Account 10 Account 11 Account 12 Account 13 Account 14 Account 15 Account 16 Amount/ % of salary Period Goal (Retirement, Major Purchase, Education) 2
Incomes Pre-tax. (use net rental income as needed) Current Expenses Exclude savings, liability payments, insurance (life and disability premiums only) and income tax. Frequency Type Amount Period Start End Start Period End Amount Frequency Index % CPP/QPP & OAS Retirees current monthly Pre-tax income from: CPP/QPP OAS If not yet retired, have you contributed to CPP/QPP most of your adult life? What will your CPP/QPP retirement benefit be at age 65? Are you considering taking your CPP earlier or later than age 65? Service Canada 1-800-277-9914 Defined Benefit Pensions Member Retiree s current monthly benefit Pension 1 Pension 2 Indicate indexing rate if applicable. If still contributing, provide copy of most recent pension plan statement. Estimate Annual Amount (today s $) Index % Survivor Benefit % Notes/Assumptions (i.e., Pension Bridge Benefits, CPP Benefit Start Age, etc ). Insurance Life Insurance Insurance 1 Insurance 2 Insurance 3 Insurance 4 Policy Type Expiry Date Payor Insured Beneficiary Death Benefits Premium Amount Cease Date Cash Surrender Value 3
Insurance cont. Disability Insurance Policy Type Payor Insured Waiting Period Benefits Maximum Benefit Amount Benefit Period Premium - Amount Cease Date Long-term Disability Short-term Disability Critical Illness Insurance Policy Type Insured Owner Benefit Amount Benefit Taxable % Benefit Period Premiums - Amount - Frequency - Payer - Cease at Age/Cease on Date - Index Insurance 1 Insurance 2 Financial Goals Retirement Expense - Premium Refund % Exclude life insurance premiums, liability payments, savings strategies, and income tax. Member Amount Frequency Start Year End Year Index % Retirement Income Exclude Investment income, CPP/QPP, OAS and company pensions already stated. Income Member Amount Frequency Start Year End Year Education Are specific assets reserved for this goal? If so, please specify. Child s Name Start Year Annual Cost Index % # of years to pay Major purchase Are specific assets reserved for this goal? If so, please specify. Member Target Date Amount Index % 4
Personal Holding Company Corporation Details Corporation Name Province of Incorporation Province of Taxation Corporate year end Unanimous Shareholders Agreement (USA) Consider the estate implications if only one director/officer. Does one exist (if yes: date signed) List signatories Buy/sell provisions (shot gun?) Payment terms key provisions (attach list) Tax Account Values Retained earnings per financial statements Value at end of previous year RDTOH CDA No capital loss cfwd Capital loss carry over Outstanding shareholder loans to the company Current loan Balance Estate Details Note # 1 You should consider preparing a separate worksheet for each company in the group. Share options at first death Share options at second death/or death in a same year Estate Freeze date & notes Family Trust Settlor Trustee(s) Date settled Nature of the trust (Intervivos, testamentary) Beneficiaries interest (fixed, discretionary) Capital Beneficiaries Income beneficiaries Beneficiaries locations (attach list) Listing of assets owned and details Legal and tax advisors 5
Personal Holding Company cont. Shareholders Common Shares # of shares Estimated Fair value PUC ACB Date issued Family Trust TOTAL Preferred Shares # of shares Redemption value PUC ACB Date issued Family Trust Corporate Assets Note # 1 You should consider preparing a separate worksheet for each company in the group. Investment Account (1) Investment Account (2) Real Estate Equipment IPP RCA Subsidiaries Note #1 Subsidiaries s Current Value Cost Base Growth Rate Contributions (INTER-COMPANY dividend) Withdrawals (Manual dividends) Life Insurance Insured (Y/N) Policy Type Benefit Beneficiary Premium Purpose 6
Will and Estate Advisor/Personal Representatives Provide name/address/phone for the following advisors/personal representatives. You Your /Partner Power of Attorney for Property* Personal Care Power of Attorney/Mandate/ Representation Agreement Accountant Lawyer/Notary Broker/Portfolio Manager Life Insurance Agent Executor Power of Attorney Is the Power of Attorney enduring? No Yes If more than one attorney must they act together No Yes Have you had any estate planning advice from lawyers or accountants that should be considered? No Yes Sole Joint Box. No: Location address Safety Deposit Boxes Do you hold a Power of Appointment over any assets? No Yes (if yes, please provide details) Powers of Appointment If you are a beneficiary of an existing estate or trust, please provide details. Interest in other Estate and Trusts Assets Held for s Do you have assets registered in your name which are held on behalf of others? (e.g. assets held by you as a trustee or asset held under a Power of Attorney.) No Yes (if yes, please provide details) Detailed Asset Information (i) Are there any U.S. securities owned directly? No Yes If yes, what is the value of those securities? $ (ii) Are there any other foreign securities held directly? No Yes If yes, what is the value of those securities? $ what is the value of those securities? $ In what country are they situated? Additional Personal Information Are you or have you ever been a US citizen? No Yes SIN Have you renounced the family Patrimony? (Quebec only) Ever Divorced? If divorced, any continuing financial obligations? 08/13-1548 Hassan Wealth Advisory Group Registered trade-marks of Bank of Montreal. 7