Personal Information
Personal Information
Name(s):
Nickname(s):
Address:
Address 2:
City: State: Zip:
Phone: Fax:
Email:
Client 1Client 2
Birth date:
Social Security:
Employer Information
Client 1Client 2
Status:
Occupation:
(If retired, previous occupation)
Employer:
Address:
Address 2:
Phone:
Family Members
Include children as well as other persons who rely on you for their support.
NameRelationshipBirthdate
Assets
Personal Assets
DescriptionOwnerCurrent ValuePurpose
'$'
'$'
'$'
'$'
'$'
Cash Assets
DescriptionOwnerCurrent ValuePurpose
'$'
'$'
'$'
'$'
'$'
Rental/Business Assets
DescriptionOwnerCurrent ValuePurpose
'$'
'$'
'$'
'$'
'$'
Fixed/Equity Assets
DescriptionOwnerCurrent ValuePurpose
'$'
'$'
'$'
'$'
'$'
'$'
'$'
'$'
'$'
'$'
Retirement Assets
DescriptionOwnerCurrent ValuePurpose
'$'
'$'
'$'
'$'
'$'
Liabilities
Liabilities, Loans, Leases
Liability 1Liability 2 Liability 3
Description:
Debtor/leasor:
Interest rate %:
Payment (prin. + int.):
Payment frequency:
Balance/residual:
OR:
Original balance:
Origination date:
Original term in months:
Liability 4Liability 5 Liability 6
Description:
Debtor/leasor:
Interest rate %:
Payment (prin. + int.):
Payment frequency:
Balance/residual:
OR:
Original balance:
Origination date:
Original term in months:
Liability 7Liability 8 Liability 9
Description:
Debtor/leasor:
Interest rate %:
Payment (prin. + int.):
Payment frequency:
Balance/residual:
OR:
Original balance:
Origination date:
Original term in months:
Liability 10Liability11 Liability 12
Description:
Debtor/leasor:
Interest rate %:
Payment (prin. + int.):
Payment frequency:
Balance/residual:
OR:
Original balance:
Origination date:
Original term in months:
Policies
Life Insurance
Policy 1Policy 2 Policy 3Policy 4
Type of insurance:
Company name:
Death Benefit:
Person insured:
Owner:
Beneficiary:
Cash value:
Premium amount:
Payment frequency:
Policy 5Policy 6 Policy 7Policy 8
Type of insurance:
Company name:
Death Benefit:
Person insured:
Owner:
Beneficiary:
Cash value:
Premium amount:
Payment frequency:
Disability Income Insurance
Policy 1Policy 2 Policy 3Policy 4
Group or individual:
Company name:
Person insured:
Wait period (days):
Benefit period (years):
Disability benefit:
Benefit frequency:
Premium amount:
Payment frequency:
Long-Term Care Policies
Policy 1Policy 2 Policy 3Policy 4
Company name:
Person insured:
Wait period (days):
Benefit period (years):
Long-term care benefit:
Benefit frequency:
Premium amount:
Payment frequency:
Income
Earned Income
Client 1Client 2
AmountFrequency AmountFrequency
Salary/wages (gross): '$' '$'
Bonus (gross): '$' '$'
Self-employment: '$' '$'
Other: '$' '$'
Other: '$' '$'
Other: '$' '$'
Investment Income
Client 1Client 2
AmountFrequency AmountFrequency
Taxable interest/dividends: '$' '$'
Tax-exempt interest/dividends: '$' '$'
Rental real estate: '$' '$'
Passive income: '$' '$'
Other: '$' '$'
Other: '$' '$'
Current Retirement Income
Client 1Client 2
AmountFrequency AmountFrequency
Pension: '$' '$'
Annuity distribution: '$' '$'
IRA distribution: '$' '$'
Social Security benefit: '$' '$'
Other: '$' '$'
Other: '$' '$'
Other Income
Examples include: alimony child support trust income
Client 1Client 2
AmountFrequency AmountFrequency
Other: '$' '$'
Other: '$' '$'
Other: '$' '$'
Expenses
Income Taxes
Client 1Client 2
AmountFrequency AmountFrequency
Federal income tax withholding and/or estimated payments: '$' '$'
State and local income tax withholding and/or estimated payments: '$' '$'
FICA (Social Security) tax withholding: '$' '$'
Retirement Plan Contributions
Examples include: IRA 401(k) profit sharing 403(b) other qualified plans
DescriptionContribution AmountFrequency Employer contribution (% or $)
Client 1: '$'
'$'
'$'
Client 2: '$'
'$'
'$'
Systematic Savings Contributions
Examples include: payroll deductions monthly bank authorizations regular investment savings
Client 1Client 2
DescriptionAmountFrequency AmountFrequency
'$' '$'
'$' '$'
'$' '$'
'$' '$'
Discretionary Expenses
AmountFrequency
Cable TV: '$'
Dining: '$'
Dues: '$'
Entertainment: '$'
Gifts to charities: '$'
Gifts to family and others: '$'
Hobbies: '$'
Recreation: '$'
Subscriptions '$'
(newspapers, magazines, on-line, etc.):
Travel: '$'
Other (pets, allowances, kids sports, etc.):
'$'
'$'
'$'
Committed Expenses
AmountFrequency
Housing
Rent: '$'
Home/rent insurance premium: '$'
Real estate taxes: '$'
Utilities (electric, fuel, water): '$'
Other (lawn, snow, etc.): '$'
Food, clothing, transportation
Food/groceries: '$'
Clothing: '$'
Auto insurance premiums(s): '$'
Auto maintenance (oil, fuel, filters): '$'
Vehicle tax: '$'
Other (tolls, bus, taxi): '$'
Loan payments
Mortgage: '$'
Auto: '$'
Other: '$'
Other: '$'
Other committed expenses
Alimony: '$'
Bank charges: '$'
Charge accounts/credit cards: '$'
Child support: '$'
Dependent care: '$'
Education costs: '$'
Home improvement/repairs: '$'
Medical costs: '$'
Prescription drugs: '$'
Personal care (hair, dry cleaning, etc.): '$'
Premiums (medical insurance): '$'
Premiums (umbrella insurance): '$'
Premiums (other): '$'
Phone (local, long distance, cellular): '$'
Unreimbursed employee expenses: '$'
Other:
'$'
'$'
'$'
Comments

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770-609-4235



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