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Questionnaire

General Information
 
 
 
 
Assets
Bank Accounts
Account NameOwnerBalance
 
Taxable Accounts (Please provide statements)
Account NameCompanyOwnerBalance
 
Business Ownership
Business NameOwnerBusiness TypeAppraisal (your share)
 
Retirement Accounts (401(K), 403(B), IRA, SEP-IRA, Simple IRA)
Account NameCompanyOwnerBalance
 
Assets Held for Education (529 Plan, Prepaid Tuition, Custodial Account)
Account NameTypeOwnerBeneficiaryBalance
 
Liabilities
Mortgages
MortgagesBalance RemainingTerm RemainingInterest Rate
 
Other Debt
DebtBalanceInterest Rate
 
Income and Retirement Analysis
 
Pensions
Client NameMonthly Amount at StartAge at StartInflation COLA
 
Pensions - What payout option does this pension represent?
 
Social Security
Client NameAge to Start PaymentsEstimated Monthly Payments
 
Other Expenses
 
Insurance Analysis
Life Insurance: Term Policies
Face ValueInsured NameGroup or IndividualTerm RemainingPremium/Yr
 
Life Insurance: Permanent Policies
Face ValueTypeYear PurchasedInsured NameCash ValuePremium/Yr
 
Long Term Disability Insurance
Name of AccountMonthly BenefitGroup or IndividualPremium/Yr
 
Long Term Care Insurance
NameDaily BenefitInflation RiderTermPremium/Yr
 
Estate Planning
 
Insurance Analysis
Notes
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