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FINANCIAL PLANNING INFORMATION DATA SHEET
(Please fill in prior to your appointment. If not sure, leave blank.
Print clearly. OK to approximate amounts. Please bring in most recent tax return.)


CLIENT NAME__________________________________________________
SS#____________________ DOB__________ AGE_____
SPOUSE NAME__________________________________________________
SS#____________________ DOB__________ AGE_____
MAILING ADDRESS __________________________________________________
CITY_________________________ STATE__________   ZIP__________
HOME PHONE (_____)_________________ BUSINESS PHONE (_____)____________
E-mail ______________________________________________________
DEPENDENTS NAME(S) and DATE(S) of BIRTH _________________________________
Do you have a current will? Y ____ N ____ Living Trust? Y ____ N ____
Are you concerned about possible Nursing Home Expenses? Y ____ N ____
                   
   
 
AMOUNTS IN BANKS, SAVINGS & LOANS & CREDIT UNIONS (NON-IRA)
(i.e., Checking, Savings, Money Market)
NAME OF INSTITUTION TYPE OF ACCOUNT MATURITY DATE INTEREST RATE APPROXIMATE BALANCE
1.__________ ___________ ____________ ____________ $ __________
2.__________ ___________ ____________ ____________ $ __________
3.__________ ___________ ____________ ____________ $ __________
4.__________ ___________ ____________ ____________ $ __________
5.__________ ___________ ____________ ____________ $ __________
6.__________ ___________ ____________ ____________ $ __________


IRA ACCOUNTS AND OTHER RETIREMENT ACCOUNTS
(Please bring in latest report/statements.)
ACCOUNT TYPE & LOCATION (BANK, BROKER, EMPLOYER) TYPE (401K, IRA, TSA, ETC.) APPROXIMATE MARKET VALUE
1._________________ _________________ $ _______________
2._________________ _________________ $ _______________
3._________________ _________________ $ _______________
4._________________ _________________ $ _______________


Planned retirement date: __________ or if retired, date retired: __________




STOCKS AND BONDS
(WHERE YOU HOLD CERTIFICATES YOURSELF)
NAME OF STOCK/BOND NUMBER OF SHARES APPROXIMATE MARKET VALUE
1._________________ _________________ $ _______________
2._________________ _________________ $ _______________
3._________________ _________________ $ _______________
4._________________ _________________ $ _______________


MUTUAL FUNDS AND/OR BROKERAGE ACCOUNTS
(Please bring in latest report/statements.)
NAME OF BROKERAGE FIRM OR MUTUAL FUND NUMBER OF SHARES APPROXIMATE MARKET VALUE
1._________________ _________________ $ _______________
2._________________ _________________ $ _______________
3._________________ _________________ $ _______________
4._________________ _________________ $ _______________
5._________________ _________________ $ _______________
6._________________ _________________ $ _______________


PROMISSORY NOTES & TRUST ACCOUNTS
(Where someone owes or is paying you on a note)
NAME OF DEBTOR INTEREST RATE APPROXIMATE MARKET VALUE
1._________________ ______________ % $ _______________
2._________________ ______________ % $ _______________


RESIDENCE AND OTHER REAL ESTATE OWNED
(Use another sheet if more space is needed)
PROPERTY ADDRESS ORIGINAL COST APPROX. VALUE DEBT NET CASHFLOW BEFORE DEPREC (if a rental)
1.__________ $ _________ $ __________ $ __________ $ __________
2.__________ $ _________ $ __________ $ __________ $ __________
3.__________ $ _________ $ __________ $ __________ $ __________


LIMITED OR GENERAL PARTNERSHIPS

NAME OF PARTNERSHIP TYPE OF INVESTMENT APPROXIMATE MARKET VALUE or AMOUNT INVESTED
1._________________ _________________ $ _______________
2._________________ _________________ $ _______________
3._________________ _________________ $ _______________


OTHER ASSETS (ie Furnishings, Automobiles and Collectibles) and LOANS/CREDIT CARD BALANCES
1. ________________________________________________ $ _________
2. ________________________________________________ $ _________
3. ________________________________________________ $ _________
4. ________________________________________________ $ _________
5. ________________________________________________ $ _________


LIFE INSURANCE
(Please bring in policies and latest statements)
COMPANY NAME OF INSURED TYPE OF INSURANCE (WHOLE LIFE, TERM) APPROX. DEATH BENEFIT LOAN AGAINST?
1.__________ ___________ ____________ $ __________ $ __________
2.__________ ___________ ____________ $ __________ $ __________
3.__________ ___________ ____________ $ __________ $ __________


ANNUITIES
(Please bring in policies and latest statements)
COMPANY ANNUITANT OWNER INTEREST RATE APPROX. VALUE DATE PURCHASED
1.__________ ___________ _________ % $ __________ ____________
2.__________ ___________ _________ % $ __________ ____________
3.__________ ___________ _________ % $ __________ ____________


HOUSEHOLD CASH FLOW
(Please bring in a recent paystub.)
CLIENT'S WAGES $______________ /YR SOURCE: ____________________
SPOUSE'S WAGES $______________ /YR SOURCE: ____________________
OTHER INCOME 1. ____________ /YR SOURCE: ____________________
  2. ____________ /YR SOURCE: ____________________
WHAT ARE YOUR APPROXIMATE ANNUAL EXPENSES: $_______________ /YR
What are your primary financial concerns? (List in order of importance.)
How would you improve your financial situation if you could? Why?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________





Cash Flow Analysis


Gross Income Client Spouse
Employment (wages, salaries, bonuses) _______ _______
Self-employment income _______ _______
Dividends/ Interest/Capital Gains _______ _______
Social Security _______ _______
Pension(s) _______ _______
Other Income: ____________ _______ _______
Other Income: ____________ _______ _______

TOTAL GROSS INCOME $ ____________


Expenses
Household expenses
Rent or Principal mortgage payments (principal and interest, only) _______
Lines of Credit/ Second Mortgages _______
Real Estate Taxes _______
Telephone, Electric, Oil, Natural Gas, Water, Cable _______
Homeowners' insurance _______
Other household - lawn care, snowplowing, maid, pool, etc. _______


Food, Clothing, Transportation expenses
Food/Groceries _______
Clothing/laundry/dry cleaning _______
Auto maintenance (gas, car wash and repairs) and Auto Insurance _______
Auto loan payments _______
Other Transportation - parking, MBTA, carpool, auto excise, etc. _______


Other Committed Expenses
Education costs - college, adult education, etc. _______
Personal Care (beauty parlor, haircuts, manicure, therapy, etc.) _______
Medical/Dental/Prescriptions (unreimbursed by health insurance) _______
Other loans - school, personal, etc. _______
Credit Card payments _______
Daycare/Childcare/Children's Activities _______
Life Insurance premiums _______
Disability Insurance premiums _______
Medical/Dental Insurance premiums _______
Other Insurance - liability, boat, etc. _______
Other Committed - alimony/child support, etc. _______


Discretionary expenses
Entertainment and Dining Out _______
Recreation/Hobbies/Club Dues _______
Vacation(s) _______
Cash Charitable Donations _______
Gifts _______
Pets _______
Tobacco/Alcohol/Lottery _______
Children's Allowances _______
Newspapers/Magazines _______
Licenses/Union or Professional Dues _______
Other Discretionary _______


Savings/Investments
Client Retirement Savings (401K, 403B, Pension, etc.) _______
Spouse Retirement Savings (401& 403B, Pension, etc.) _______
IRA funding (Regular or Roth) _______
Other Savings/ Investments (College, etc.) _______


Income Taxes Withholdings
Client: Federal Income Taxes Withholdings _______
Client: State Income Taxes Withholdings _______
Client: Social Security and Medicare Withholdings _______
Spouse: Federal Income Tax Withholdings _______
Spouse: State Income Tax Withholdings _______
Spouse: Social Security and Medicare Withholdings _______


TOTAL EXPENSES $ ____________
DISCRETIONARY INCOME
(Total Gross Income less Total Expenses) 		$ ____________