Investment Type Assets (Stocks, Bonds, Mutual Funds, Etc.)

General Information
Family Data: / Date of Birth / Birth Place / Social Security Number
Your Full Name / n/a / n/a
Spouse’s Full Name / n/a / n/a
Child / n/a / n/a
Child / n/a / n/a
Child / n/a / n/a
Child / n/a / n/a
Residence: Street Address
City State Zip
Telephone / Fax / E-Mail Address
Employment Data: / Occupation / Employer / How Long?
You
Spouse
Your Employer’s Address City State Zip Phone#
Spouse’s Employer’s Address City State Zip Phone#
Your Work E-Mail Address / Spouse’s Work E-Mail Address
Base Salary / Estimated Bonus / Estimated Commission / Estimated Stock Option
Your Primary Income
Spouse’s Primary Income
Other Income: / Source 1 Amt / Source 2 Amt / Source 3 Amt / Source 4 Amt
Rentals
Royalties
Secondary Business Income $ ☐Sole Proprietor ☐Partnership ☐Corporation ☐LLC
Real Estate
Property
Description / Purchased
Year / Purchased
Price / Improvements or Capital Expenditures / Current market value (estimated)
Your Residence / $ / $ / $
Other Home / $ / $ / $
Other Home / $ / $ / $
Other / $ / $ / $
Other / $ / $ / $
Other / $ / $ / $
Mortgage/Equity Line of Credit
Interest Rate / Monthly Payment
Net of Real Estate Tax / Months
Remaining / Unpaid
Balance
Your Residence / % / $ / $
Other Home / % / $ / $
Other Home / % / $ / $
Other / % / $ / $
Other / % / $ / $
Other / % / $ / $
Loans, Debt & Personal Property
(include personal loans, college loans, home improvement loans, automobile or boat loans, passbook loans, credit card balances, checking credit lines, include mortgage if you’re pay more than minimum payment etc.)
Interest Monthly Actual Months Unpaid
Type of Loan Rate Payments Payment Remaining Balance
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
% / $ / $ / $
Assets and Liability Information
Savings Type Assets(List each account separately, by ownership and amount)
Item / Institution / Annual Contribution / Total
Savings Account / $ / $
Credit Union / $ / $
Savings Bonds (Type) / $ / $
Certificate of Deposit / $ / $
Money Market Fund / $ / $
Single Premium Deferred Annuity / $ / $
I.R.A. / $ / $
Keough Plan / $ / $
Pensions/Profit Sharing / $ / $
SEP / $ / $
Checking Account / $ / $
1. Other / $ / $
2. Other / $ / $
3. Other / $ / $
4. Other / $ / $

Investment Type Assets (Stocks, Bonds, Mutual Funds, etc.)

Item / Institution / Annual Contribution / Total
Government Securities / $ / $
T. Bills, Notes, Bonds / $ / $
GNMA, CMP etc. / $ / $
Corporate Bonds / $ / $
Municipal Bonds / $ / $
Stocks / $ / $
Mutual Funds / $ / $
Partnerships / $ / $
Other / $ / $
SEP / $ / $
Checking Account / $ / $
1. Other / $ / $
2. Other / $ / $
3. Other / $ / $
4. Other / $ / $
Insurance Coverages

Life Insurance

Insurance Company / Insured / Annual Premium / Annual Dividend / Policy Loan / Cash Value / Amount of Coverage
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $

Disability Insurance

Insurance Company / Insured / Annual Premium / Monthly Benefit / Waiting Period / Duration of Benefit
$ / $
$ / $
$ / $

Property & Casualty Insurance

Insurance Company / Insurance Company / Annual Premium / Bodily InjuryLiability Limits / UninsuredMotorist
Liability Limits / Deductibles Collision/Comp
Automobile Insurance / $ / $ / $ / $
Homeowners Insurance / $ / $ / $ / $
Personal Liability Insurance / $ / $ / $ / $
Other / $ / $ / $ / $

Additional Information

Do you have Valid, Executed Wills?...... ☐Yes ☐No

Do you have an Attorney?...... ☐Yes ☐No

Do you have an Accountant?...... ☐Yes ☐No

Are you a Smoker………………………………………….☐Yes ☐No

Is your spouse a Smoker?...... ☐Yes ☐No

Please use the area below if additional space is needed for your responses.