CLIENT INFORMATION WORKSHEET

Client Name: ______Spouse Name: ______

Social Security #: ______Spouse Social Security#:______

Birthdate: ______SpouseBirthdate: ______

Employer: ______Spouse Employer: ______

Address: ______

City, State, Zip: ______

Phone: ______

Fax: ______

E-mail: ______

Please list children below:

NameDate of BirthSocial Security Number:

Financial Goals:

  1. At what age would you like to retire? ______Your spouse?______
  1. Amount in today’s dollars would you need each year to live on at retirement?

______$100,000______$150,000 ______$200,000 ______Other

  1. Are you interested in establishing college funds for your children? ______If so, how much would you like to provide in today’s dollars for each child for each year of college? ______For how many years of college?______How much do you currently have saved for each child for college?

ChildAmount Saved

______

______

______

Please list below any other personal financial goals.

Monthly Budget:

Net Monthly Income –

Yourself$______

Spouse$ ______

Total Net Monthly Income$______

Monthly Expenses

Federal Taxes$______

State Taxes$______

Retirement – Husband$______

Retirement – Wife$______

Mortgage$______

2nd Mortgage$______

Homeowners Insurance$______

Real Estate Taxes$______

Auto Note – 1$______

Auto Note - 2$______

Auto Insurance – 1$______

Auto Insurance - 2$______

Auto – Gas$______

Auto – Repairs$______

Health Insurance$______

Life insurance$______

Disability insurance$______

Student loans$______

Tuition$______

Gas$______

Electric$______

Water$______

Cable$______

Telephone$______

Cell $______

Dry Cleaning$______

Dues$______

Alarm$______

Grooming$______

Food$______

Vacations $______

Credit Cards$______

Entertainment $______

Pets$______

Lawn services$______

Maid services$______

Monthly Budget (continued):

Home maintenance$______

Presents$______

Clothes$______

Education Funds$______

Health Club$______

Child Care$______

Baby Sitters$______

Other: ______$______

Other: ______$______

Other: ______$______

Other: ______$______

Total Expenses$______

Total Surplus <Deficit>$______

List of Outstanding Debts:

Home Mortgage
Amount Financed______
Interest Rate______

Amortization______years

Date of Loan______

Principal & Interest Payments______

Auto

Amount Financed______
Interest Rate______

Amortization______years

Date of Loan______

Principal & Interest Payments______

Please list below the details of any other debts (other than credit card debts)

Net Worth Information:

Amount Currently in Checking$______

*List Below All Investments Accounts – Non–Retirement and the estimated value of each account:

1.______$______

2.______$______

3.______$______

4.______$______

*List Below Any IRA’s and the estimated value of each IRA:

1.______$______

2.______$______

3.______$______

4.______$______

*List all Employer Sponsored Retirement plans, the estimated value of each plan, amount you contribute each year, and the amount your employer contributes to the plan each year:

Name ofPlan Value Employee Employer

Contribution Contribution

1.______$______$______$______

2.______$______$______$______

3.______$______$______$______

4.______$______$______$______

* Please attach current statements for each account listed above to this information worksheet.
What is the estimated value of your home? ______

What is the estimated value of autos? ______

What is the estimated value of personal assets? ______

Life Insurance:

Please list below the following information related to you and your spouse’s life insurance.

Policy Annual

Company Amount Policy # Date Owner Beneficiary Type Prem

1.

2.

3.

Disability Insurance:

1. Do you and your spouse currently have disability insurance? ______

2. Is the insurance provided by your employers? ______

3. What is the amount of coverage for each of you? ______

4. Are the premiums paid with after tax dollars? ______

1