Personal Values Questionnaire

Transcription

1 al s Questionnaire 1) Mr / Mrs / Ms / Miss / Dr : 2) Mr / Mrs / Ms / Miss / Dr : Gender: Birth : Year: Gender: Birth : Year: Marital Status: Home Phone #: Marital Status: Home Phone #: Street: Street: City: ST: Zip Code: City: ST: Zip Code: Citizenship: Occupation: Citizenship: Occupation: Employer: Wk Phone: Employer: Wk Phone: Address: Address: Preferred Preferred Child / Grandchild Name Child of Birth Years of Education School (Private / Public) Cost Wedding Cost Concerns Special Needs PERSONAL FOCUS AREAS Review investments Achieve financial independence by Review life insurance Review / create a financial plan Plan f health care costs after retiring Save f a maj purchase Increase retirement income Protect lifestyle if disabled befe retirement Evaluate pension choices Protect investments from losses Start a family gifting program Diversify a large stock position Provided f special needs child Have retirement money last f years Long-term care planning Manage cash flows / debt Fund educations: K-12 / college / grad school Establish / administer a trust Establish / review estate plan Improve tax efficiency of ptfolio Stock option planning Avoid probate costs and delays Create leave a family / charitable legacy Protect assets from credits Minimize estate taxes Review beneficiary designations Sell highly appreciated assets Simplify financial management Postpone / minimize income taxes Invest a windfall / inheritance Keep estate plan simple Include our personal values into our estate plan Review home loan BUSINESS FOCUS AREAS Review / start retirement plan Sell, buy start a business Establish a continuation succession plan Equalize estate f heirs Retain / reward key employees Bring family members into business Defer compensation Buy insurance through business Protect against loss of key employee / partners FUTURE PURCHASE GOALS (First second home, maj vacation, car, rental property, business, office building, plane, art, jewelry, recreation vehicle) Priity of Goal (10=highest, 1=lowest) Purchase Purchase Savings Plan Start (Accounts that may fund this goal)

2 Financial Data PERSONAL PROPERTY Specific Asset (Home, 2nd home, rental property, business, building, plane, art, jewelry, recreation vehicle) Purpose (al Use, Income, Business) Original Purchase Current Future Sale Replacement? INVESTMENTS (please list employer contributions on a separate line) Type of Account (Regular, 529, 401k, IRA, SEP, SIMPLE, Roth, TSA, 403b, Keogh, Profit sharing, Money Purchase, Pension) Current Monthly Savings Cost Basis CUSIP Ticker Symbol Asset Class Beneficiaries (Primary and Secondary) Purpose Goal STOCK OPTIONS and STOCK APPRECIATION RIGHTS Type (Nonqualified Incentive) Company Name Ticker Symbol # of Shares Grant Price Grant Expiration Confidence Fact 1=Low / 10=High Purpose Goal ANNUITIES Company Annuitant Current s Paid / Cost Basis Monthly Savings Account? Beneficiaries (Primary / Contingent)

3 INCOME (Do not include earnings from investment accounts Please note if eligible f Social Security) Specific (Salary, Bonus, Commissions, Social Security, Business, Alimony, Child Suppt, Royalty, Pension Plan, Rental Income, Inheritance, Notes Receivable, Trust) Applicable Period (Start - End ) Expected Increase Tell us about any changes you expect in your income expenses in the next 12 months: PENSION PLANS (Please enter fmulas pension estimates) Plan Final Salary Estimate Fmula Details Pension Estimate (Years of Service, Salary, Average of Last Three Years of Service, Other Necessary Calculations) Applicable Period (Start - End ) Expected Increase INCOME TAXES FILING STATUS (Please select one): Married/Joint Married/Separate Single Head of Household Paid to IRS (on second page of fm 1040) Paid to State (on state tax return Schedule A of Federal return) Taxable Interest Ordinary Dividends Capital Gains LIABILITIES Do not include taxes insurance in mtgage payments These are considered as a part of ongoing expenses. Type / Loan Start Original Principal Balance Remaining Interest Rate Loan Type Interest only / Principal & Interest Loan Period in Years Payment Frequency Additional Payment Ongoing/ Lump Sum Balloon EXPENSES There are a variety of ways to provide a budget. Here are four. 1. Add up the withdrawal/debit amounts on checking account statements over the past six months, divide by six and enter the monthly result here $. 2. Provided the most recent pay stub along with all bank and investment statements 3. Provided a budget from a spreadsheet software program. 4. Itemize expenses on the attached Budget Wksheet.

4 ESTATE PLANNING Make entries only f the estate planning techniques that have been implemented already. Document Type Created Last Updated Created f 1st, 2nd Both Document Type Created Last Updated Created f 1st, 2nd Both Will Power of Attney - Durable Springing? Revocable Living Trust Living Will Pour-over Will Perpetual / Dynasty Trust Material "A" Trust Prenuptial Agreement Exemption "B" Trust Health Care Directives Qualified Terminal Interest Property (QTIP) Divce / Separation Agreement Discount Taken ship Retained Type (Intentionally Defective / Qualified al Residence) Taxable Income Family Limited Partnership % % Grant Retained Trust Charitable Trust (Remainder / Lead) Income Deduction Years Remaining Type (Annuity = Set / Unitrust = Set percentage) Applicable Period (Start - End ) DISABILITY INSURANCE PROVIDED BY EMPLOYER OWNED INDIVIDUALLY Employer Sponsed Insurance Provider Insured Waiting Period in Days Sht Long Term Period (Weeks / Months / Years) (% of Salary) Taxable Paid by Insured (Monthly) LIFE INSURANCE OWNED Insured Guarantee Period (in years) Cash Frequency Loan Purpose (i.e., replace lost income, payoff debts, maintain lifestyle, provide f retirement savings, cover other goals, estate planning) LONG-TERM CARE INSURANCE OWNED Self Insure? Insurance Company of Existing Policy Insured Daily Years of Level / 5% Simple / 5% Compound Payment Frequency Years of Payments

5 Please print clearly ASSUMPTIONS ESTATE PLANNING At Death of Probate Cost % Estate Tax Expectations (as Legislated / Repealed / Specific ) Expected Growth Estate State Death Tax $ % Show Use of Maximum Exemption Gifts Filed Gift Tax Return Befe? % % % $ % $ % % % $ % $ of Lifetime Gift Exclusion Used Show charitable bequest of at death of. Show charitable bequest of at death of. DISABILITY Cover befe Cover after Inflation Investment Risk Profile Include Exclude Debts (that may be used f this goal) % % % % % % DEATH Cover befe Cover after Inflation Investment Risk Profile Include Exclude Debts (that may be used f this goal) % % LONG TERM CARE Daily Cost of Care Percent of Assets to Protect Inflation on Cost of Care Age to start Receiving Care Years to Pay f Care (if it is required) Exclude Debts (that may be used f this goal) % % % % Is there anything else that we should consider?.

6 CHECKLIST FOR FINANCIAL PLANNING Please send bring copies of the following items to our office: Current investment statements Most recent Social Security benefit statements Pension statements and/ booklets with pension fmulas Current pay stubs Most recent federal and states income tax returns Employee benefit statements and booklets s of titled personal assets Current mtgage statements, igin date and amount Annuity statements Checking account statements f the past six months Current wills, trust documents and any other legal documents Life, disability and long-term care insurance policies with statements and illustrations Stock option and restricted stock statements Bonus plans Deferred compensation arrangements Please include the flowing business related items: Current profit and loss statement Entity agreements Buy-sell agreements Business insurance policies, statements and illustrations plan document Please include copies of your notes Please print clearly