Personal Information

Your Name
Address
Work Address
Spouse/Partner Name
Date

Dependents (please include adult dependents)

Dependent 1
From previous Marriage?
Dependent 2
From previous Marriage?
Dependent 3
From previous Marriage?
Dependent 4
From previous Marriage?
Dependent 5
From previous Marriage?
Dependent 6
From previous Marriage?

Financial Position

Rate the Level of Importance of Each Area*
Rate the Level of Importance of Each Area
  1 2 3 4 5
Budgeting (living within your means)
Amount of emergency cash reserves
Safety or rate of return on cash reserves
Liquidity of cash reserves
Cost of debt
Other:
Rate the Level of Satisfaction with Current Results*
Rate the Level of Satisfaction with Current Results
  1 2 3 4 5
Budgeting (living within your means)
Amount of emergency cash reserves
Safety or rate of return on cash reserves
Liquidity of cash reserves
Cost of debt
Other:

Risk Management

Rate the Level of Importance of Each Area*
Rate the Level of Importance of Each Area
  1 2 3 4 5
Your family's lifestyle in event of death or disability
Payment of medical expenses
Personal or business liability coverage
Replacement of auto, home, or other property in event of loss
The level of volatility of your investments
Unforeseen costs of caring for an aging or disabled relative
Other:
Rate the Level of Satisfaction with Current Results*
Rate the Level of Satisfaction with Current Results
  1 2 3 4 5
Your family's lifestyle in event of death or disability
Payment of medical expenses
Personal or business liability coverage
Replacement of auto, home, or other property in event of loss
The level of volatility of your investments
Unforeseen costs of caring for an aging or disabled relative
Other:

Wealth Accumulation

Rate the Level of Importance of Each Area*
Rate the Level of Importance of Each Area
  1 2 3 4 5
Education for children or grandchildren
New or second home
Special vacation
Weddings, Bar- or Bat-Mitzvahs
Purchase of business
Liquidity of cash reserves
Other:
Rate the Level of Satisfaction with Current Results*
Rate the Level of Satisfaction with Current Results
  1 2 3 4 5
Education for children or grandchildren
New or second home
Special vacation
Weddings, Bar- or Bat-Mitzvahs
Purchase of business
Liquidity of cash reserves
Other:

Tax Planning

Rate the Level of Importance of Each Area*
Rate the Level of Importance of Each Area
  1 2 3 4 5
Taking advantage of all available tax reduction strategies
Reducing federal and state income taxes on earned income
Reducing federal and state income taxes on investment income
Reducing federal and state income taxes on future income
Alternative Minimum Tax
Sale of a highly appreciated or low cost basis asset or real estate
Other:
Rate the Level of Satisfaction with Current Results*
Rate the Level of Satisfaction with Current Results
  1 2 3 4 5
Taking advantage of all available tax reduction strategies
Reducing federal and state income taxes on earned income
Reducing federal and state income taxes on investment income
Reducing federal and state income taxes on future income
Alternative Minimum Tax
Sale of a highly appreciated or low cost basis asset or real estate
Other:

Retirement Planning

Rate the Level of Importance of Each Area*
Rate the Level of Importance of Each Area
  1 2 3 4 5
Taking advantage of all available tax reduction strategies
Reducing federal and state income taxes on earned income
Reducing federal and state income taxes on investment income
Reducing federal and state income taxes on future income
Alternative Minimum Tax
Sale of a highly appreciated or low cost basis asset or real estate
Other:
Rate the Level of Satisfaction with Current Results*
Rate the Level of Satisfaction with Current Results
  1 2 3 4 5
Taking advantage of all available tax reduction strategies
Reducing federal and state income taxes on earned income
Reducing federal and state income taxes on investment income
Reducing federal and state income taxes on future income
Alternative Minimum Tax
Sale of a highly appreciated or low cost basis asset or real estate
Other:

Anticipated Changes

Please check all that are likely to occur within the next 12 months.

Household Income

Wages, commission, alimony, child support, pension, annuity, social security, etc.

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Type of Assets Owned

Please check all that apply.
How Much of a Financial Risk Taker are You?
How Much of a Financial Risk Taker are You?
  1 2 3 4 5 6 7 8 9 10
Risk Level
1 = Low Risk | 10 = High Risk

Net Worth

Home, Vehicles, & Personal Property

ASSETS

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LIABILITIES

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Liquid Assets / Retirement

ASSETS

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LIABILITIES

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Business / Real Estate Holdings

ASSETS

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LIABILITIES

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Assets - Liabilities = Net Worth

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$

Life Principles

S.P.R.I.F. - Are you satisfied with your:

Financial Position

Risk Management

Wealth Accumulation

Tax Planning

Retirement Planning

Estate Planning

Other

Documents Needed for the Next Meeting

The following documents will be needed for study and analysis as we work together to create a financial strategy for you. It is understood that this material will be treated confidentially and returned when the plan is completed, or earlier if re- quested.

Most Recent Payroll Stubs
Income Tax Returns
Insurance Policies and/or Statements
Investments and Retirement Statements Booklets and/or plan descriptions
Employee Benefit Statements/
Will and Trusts
Business Documents
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