Complete Financial Review Form

This form requires some detailed information. Before completing it you might want to have the following documents on hand: your most recent tax returns, current pay stubs, insurance policies, and bank and investment statements.

Personal Information Your Name:  First/Middle: Last: Address:    City State  AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY  ZIP Phone:  Fax: Email Address:  Age:  Spouse's Name*:  First/Middle: Last: * optional

Do you have: Dependents  A Will  A Revocable Living Trust

Your Goals   0-5 Years 5-10 Years 10+ Years Not Planned Start a Family First Home Bigger Home A Special Vacation Home Improvements New Car Private School Tuition Second (Vacation) Home College Tuition A Comfortable Retirement At what age to you plan to retire? Other Short-Term (1-5 years) Goals: Other Mid-Term (5-10 years) Goals: Other Long-Term (More Than 10 years) Goals:

Annual Household Income Salary or Wages $ Commission $ Distributed Net Profits $ Investment Income $ Other Income $ Bonus $ Total $

Most Recent Taxes Local Income Tax $ State Income Tax $ Federal Income Tax $ FICA/Medicare Taxes $ Other Taxes (Local, School, Poll, County, etc.) $ Total $

Types of Insurance You Have Life   Cash Value   Term Disability Income Personal Health Long-Term Care Homeowner's or Renter's Umbrella Liability

Do you have any of the following liabilities? (Check all that apply) Mortgages   Residential Mortgage   Vacation Property Mortgage   Other Mortgage Loans   Auto Loan   Insurance Policy Loan   Private Loan   Other Credit Cards   Visa   Master Card   American Express   Discover   Diner's Club   Gas Stations   Retail Stores

Do you own any of the following assets? (Check all that apply) Real Estate Checking Accounts Passbook Savings Money Market Funds:   Bank Money Market Funds   Mutual Fund Money Market Funds Certificates of Deposit Mutual Funds Stocks Bonds Annuities Limited Partnerships Traditional IRAs Roth IRAs 401(k) or other Profit Sharing Plans Other Retirement Programs I receive periodic Gifts I am the beneficiary of a Trust I own all or part of a Business Other investments or items of value (art, antiques, jewelry, collectibles etc.)

Real Estate   Purchase Price Current Value Mortgage Balance   $ $ $   $ $ $   $ $ $   $ $ $

Checking Account Balances   Account #1: $ Account #2: $   Account #3: $ Account #4: $

Savings Account Balances   Account #1: $ Account #2: $   Account #3: $ Account #4: $

Certificates of Deposit (CDs)     Amount Maturity Date (mm/yy) Interest Rate   Certficate #1: $ / %   Certficate #2: $ / %   Certficate #3: $ / %   Certficate #4: $ / %   Certficate #5: $ / %   Certficate #6: $ / %

Bank-Sponsored Money Market Account Balances   Account #1: $ Account #2: $   Account #3: $ Account #4: $

Mutual Fund Holdings     Fund Name Current Value   Fund #1: $   Fund #2: $   Fund #3: $   Fund #4: $   Fund #5: $   Fund #6: $

Stock Holdings   Name of Stock Number of Shares Current Value   $   $   $   $   $   $

Bond Holdings   Name of Bond Face Value Current Value *   $   $   $   $   $   $ * If known

Annuity Contracts     Fixed or Variable Current Value   Contract #1:  Variable   Fixed $   Contract #2:  Variable   Fixed $   Contract #3:  Variable   Fixed $   Contract #4:  Variable   Fixed $

Limited Partnerships Name of Partnership Type Total Cost Rate of Return  Real Estate Oil & Gas Leasing Other  $ %  Real Estate Oil & Gas Leasing Other  $ %  Real Estate Oil & Gas Leasing Other  $ %  Real Estate Oil & Gas Leasing Other  $ %

Traditional IRAs     Name of Fund or Investment Current Value   Account #1: $   Account #2: $   Account #3: $   Account #4: $

Roth IRAs     Name of Fund or Investment Current Value   Account #1: $   Account #2: $   Account #3: $   Account #4: $

Value of 401(k)s or Profit Sharing Plans   Plan #1: $ Plan #2: $   Plan #3: $ Plan #4: $

Other Retirement Programs     Estimated Monthly Income at Retirement Lump Sum Distribution Available?   Plan #1 $ Yes No   Plan #2 $ Yes No   Plan #3 $ Yes No   Plan #4 $ Yes No

Gifts   How Much Do You Receive? $ How Often?

Trusts   Annual Income: $   Other Information:

Business Ownership Business Form Percent of Ownership Value of Your Share  Proprietorship Partnership Chapter S Chapter C  % $  Proprietorship Partnership Chapter S Chapter C  % $  Proprietorship Partnership Chapter S Chapter C  % $  Proprietorship Partnership Chapter S Chapter C  % $

Life Insurance   Term or Cash Value Face Amount Cash Value, Less Any Loan Annual Cost Policy #1:  Term  Cash Value $ $ $ Policy #2:  Term  Cash Value $ $ $ Policy #3:  Term  Cash Value $ $ $ Policy #4:  Term  Cash Value $ $ $

Other Investments or Items of Value   Describe:

Monthly Expenses Rent or mortgage payment $ Groceries $ Clothing $ Car Payment $ Car Insurance $ Gas/Diesel Fuel $ Tolls $ Car Maintenance $ Life Insurance $ Disability Income Insurance $ Health Insurance $ Homeowner's or Renter's Insurance $ Umbrella Liability Insurance $ Water and Sewer $ Electricity $ Heat $ Telephone $ Garbage Collection $ Cable/Satellite Television $ Home Maintenance $ Tuition $ School Supplies $ Credit Card Payments (Visa, Master Card, American Express, department store cards) $ Bank Loans other than Mortgage and Car Loans $ Other Time Payments or Debts $ Uninsured Medical/Dental Expenses (Including medication) $ Entertainment $ Gifts $ Contributions $ Organization Dues $ Subscriptions $ Vacation Savings $ Other Miscellaneous Expenses $ Tax-deferred Investments/Savings $ Taxable Investments/Savings $ Net Monthly Income $ Less Total Monthly Expenditures $ Net Discretionary Income $

Other Information or Comments