Benefits
There are several benefits to taking the time to fill out the following questionnaire:
 - The information may be shared with your accountant, lawyer, financial planner, or other professional. This will aid them in more adequately helping you.
 - The information becomes an economic diary from  which you may measure your progress.
 - The information, being all gathered in one place,  becomes an important reference to you. For some  couples, it may be the first time a balance sheet and  income statement has been prepared for both to  understand.
 - The information can be most valuable for survivors.
 - The information may be given to trusted children to help in making economic decisions.

 

inventory date:___________

Name:_____________________________ Nickname:_______________

 

Address:____________________City:__________________Zip:_________

 

Date of birth:_________________Place:________________Sex:_______

 

Social Security Number:_____-____-_____Occupation:______________

 

Business Name & Address:_____________________ Date employed:____

 

HOME PHONE:________________ Business phone:_____________

 

Spouse's Name:__________________________Nickname:_______________

 

Address:____________________

 

City:_________________Zip:_________

 

Date of birth:_________________ Place:_______________Sex:_______

 

Social Security Number:_____-____-_____Occupation:______________

 

Business Name & Address:_____________________Date employed:_____

 

Name______________ Sex  Birth Date Minor/Marr/Single/ Dependent?

 

 

OTHER DEPENDENTS YOU MAY HAVE or PERSONS YOU MAY INHERIT FROM---
Name________________  Relationship (if any)  Age___   Dependent?

 

Do you expect a sizeable inheritance?_____When?______Amount?____
Grandchildren and their ages:

 

(Please mark any of these areas that may apply to you.  Also, please feel free to add any areas not covered by this list.)
 A. General Financial Goals--I/We have plans/desires to:
    ___Reduce income taxes ___Give to charity ___Give to Relatives
    ___Increase cash reserves to $__________by when?______________
    ___Buy a house  ___Buy a vacation property  ___Buy a business
    ___Save $_________for this reason:____________________________
 

B. Income Goals--I/We have plans/desires to:
        ___Increase current income          ___Increase capital growth
1. Retirement income. Provide $___________(from all sources) monthly    retirement income. You expect to retire
(date)______________
   Your spouse expects to retire (date)____________.
2. If working, disability income. Provide for possible disability of:
  $_____________per month from all sources if you cannot work.
  $_____________per month from all sources if your spouse cannot work.
3. Provide Business continuity in case of owner disability.
4. Survivors income (in case of death).  Provide:
   At your death, provide $____________ income monthly to spouse.
   At spouse's death, provide $____________ monthly to you.
   At death of both, provide $____________ monthly to children.
5. Pay off debts in case of your death $ __________Spouses $_________
6. Provide efficient asset transfer to heirs minimizing probate costs.
7. Provide disposition of business or farm interests at death:
   ___Liquidate Business/ OR ___Keep in Family/ OR ___Sell it
8. ___Review Property/Casualty coverage  ___Health care coverage

9. ___For these named children (or other dependents), provide the       following money for the named reasons:(college/health
problems/etc.)
    Name          Amount (per mon/yr)      Reason       Need by Age

 

 

 

 C. In making Investments, do you classify yourself as:
       __Conservative OR __"Middle of the Road" OR __a Risk Taker?

        Spouse: __Conservative; __"Middle of the Road"; __a Risk Taker?
 

Your estimated before-tax income for the current 12 months:
 Source_____________________________ Amount___________________
 Your employment/retirement:
 Spouse employment/retirement:
 Interest income:
 Investment income:
 Rental:
 Other:
          TOTAL: $
 Salary review date: you________________ spouse________________
 Anticipated increase: you $____________ spouse $________________
 Average gross annual income past five years--you $____________
            --spouse $____________
 Has this income been fairly steady? ___ if not, why? ____________
 

Are you fully covered by Social Security? _____ you  ____spouse
 Will spouse elect dependent coverage? ___ If so, at what age?____
 Your estimated savings/investments over the last 12 months:
 Asset or Institution  % Earning   Amount Saved   Reg. Additions?

 Additional amount that can be set aside monthly: $_______________
 

A. Employer provided plans
                     Planned    Employer
     Plan    Date    Present   Monthly   Annual     Matching   Vesting
     Type  Eligible  Balance   Contrib.  Increase%  Percent  Schedule*
You:_____  ________  ________  ________  _________  _______  _________
"   _____  ________  ________  ________  _________  _______  _________
Spouse:___ ________  ________  ________  _________  _______  _________
  "  ____  ________  ________  ________  _________  _______  _________
 *for example, "10 years, 10% per year"

 

 B. Personal Retirement Accounts (IRA, Keogh, TSA, etc.)
IRA annual contribution: you $__________; spouse $__________
Are you eligible to deduct IRA? you________; spouse_________
Current IRA account balance: you $_________; spouse $_________
Current earnings percentage on IRA: you_______; spouse______
 Other retirement plans (such as TSA) you have:
 Other retirement plans your spouse may have:

 

 

Liability  Amount owed   Monthly pymt   Loan (%) rate   When paid off?

 

 

Are you a co-signer on any other debts?

 

 

PERSONAL ASSETS    Market Value    Rate of Return    Regular Additions?
Money Markets:
Bank/Credit Union savings:
Certificates of Deposit:
Residence value:
2nd home value:
US Savings Bonds:
Corporate Bonds:
Municipal Bonds:
Annuities (Fixed):
Other assets guaranteed in interest and/or principal:
Mutual Funds:
Other Real Estate:
Stocks:
Coins, antiques, art, etc.:
Cars, Trucks, Furniture, etc:

 *BUSINESS ASSETS  Date Began  Book Value  Market Value  Growth/yr

 Who are the owners, and their respective share?
The date of your most recent will__________; of your trust________
The name of your trust:___________________________________________
Your attorney's name and address:_________________________________
_______________________________________ phone: ___________________
Have you done any gifting yet?  If so, when, and to what extent?

If you are involved in a business, have you prepared any items such as a "buy/sell" to preserve the business? What have you?
Will spouse work after your death?_____You, after spouse's?_____
How long after the death would the other return to work?___year(s)
What would be the expected starting wage (per year)? You $______
your spouse $_____.  What rate of increase could be expected to follow the initial starting up time? You________%, or spouse_____%.
Would there be special training (education) desired first, if so,  what would the expected costs be? You $__________,
spouse $________
Would you/spouse also work during training period? ______If so,
what would be the expected earnings _________?

     Life Insurance Coverage:
Insured Company  Policy #    Amount  Premium  Beneficiary  Cash Val
you     at work   ----                                       ------
  "
  "
spouse  at work    ----                                      ------
  "
children

   (IF WORKING): Disability Income Coverage:
                                Monthly           Waiting   Benefit
Insured   Company   Policy #    Benefit  Premium  Period    Duration
you       at work    ----
  "
  "
spouse    at work    ----
  "

               Medical (Health Insurance) coverage:
      Maximum           Out of
Insured  Company  Policy #    Benefit  Premium  Deductibles  Pocket

 

Casualty - Expiration dates:  Car Insurance ______________Home________
Should you review coverage at that time?

 

                                                     Before                        After
LIABILITIES:                            Retirement                Retirement

Mortgage Payment or Rent           $________                   $________
Real estate taxes                           $________                   $________
Interest on mortgage                     $________                   $________
Vacation Home Mortgage            $________                    $________
Taxes                                          $________                    $________
Interest                                        $________                    $________
Automobile Loan                         $________                    $________
Personal Loans                            $________                    $________
Charge Accounts                         $________                    $________
TOTAL LIABILITIES                $________                    $________

 

INCOME TAXES:
Federal                                       $________                     $________
State                                           $________                     $________
Local                                          $________                     $________
TOTAL TAXES                         $________                     $________

 

SOCIAL SECURITY OR CIVIL SERVICE COSTS:
You                                            $________                      $________
Spouse                                       $________                      $________
TOTAL SOC SEC/CIVIL SERV$________                     $________

                                       

OTHER BENEFIT PLANS: (Deferred Comp., Group Life, Group Health, etc.)
You                                           $________                        $________
Spouse                                      $________                        $________
TOTAL BENEFIT PLANS COSTS:$________                $________

 

TRANSPORTATION:
Gas and Oil                               $________                        $________
Maintenance and Repair            $________                        $________
License                                     $________                        $________
Public Transportation                $________                        $________
Parking                                     $________                        $________
TOTAL TRANSPORTATION: $________                      $________

INSURANCE:
Life Insurance                            $________                       $________
Health Insurance                        $________                       $________
Disability Income                       $________                       $________
Auto Insurance                          $________                       $________
Home Owners Insurance           $________                       $________
Other                                        $________                       $________
TOTAL INSURANCE             $________                       $________

                                      SAVINGS AND INVESTMENTS:
Payroll Deductions                     $________                      $________
Credit Union                              $________                      $________
Mutual Funds                            $________                       $________
Stocks and Bonds                     $________                       $________
Real Estate                               $________                       $________
Annuities                                  $________                       $________
Face Amount Certificates         $________                       $________
Other                                      $________                        $________
TOTAL SAV & INVEST       $________                        $________

 

CONTRIBUTIONS:
Religious                                  $________                       $________
Charitable                                $________                       $________
TOTAL CONTRIBUTIONS  $________                       $________

 

COSTS SPECIFIC TO GOING TO WORK (DO NOT COUNT TWICE)
You                                       $________                         $________
Spouse                                  $________                         $________
TOTAL WORK-RELATED EXPENSE $________       $________

 

HOUSEHOLD EXPENSES:
Food                                                       $________         $________
Clothing                                                   $________         $________
Doctor (including eye care)                      $________          $________
Dentist                                                     $________         $________
Prescription Drugs                                   $________          $________
Personal Care                                         $________          $________
Gas, Electricity                                        $________          $________
Maintenance and Repair, Garbage           $________          $________
Home Furnishings                                    $________          $________
Telephone                                               $________          $________
Water                                                     $________          $________
Recreation, Entertainment, Hobbies         $________          $________
Education Expenses, Books, Magazine    $________          $________
Vacation and Travel                                $________          $________
Children Allowances                               $________           $________
Gifts                                                       $________           $________
Miscellaneous                                         $________           $________
TOTAL HOUSEHOLD                         $________           $________

TOTAL "OTHER EXPENSES"             $________           $________
(NOT LISTED ELSEWHERE)

GRAND TOTAL OF ALL EXPENSES $________          $________

1.  On a scale from one to three, with 1 being least-preferred and 3 being most-preferred, rate the following methods of investing.
                                                     Rank     Check if   Check if
                                                     Here     now using  unfamiliar
a.   Savings Account                   1  2  3  ________   ________
b.   Cash Value of Life Insurance1  2  3  ________    ________
c.   Government Bonds              1  2  3  ________    ________
d.   Corporate Bonds                 1  2  3  ________   ________
e.   Tax-exempt Bonds              1  2  3  ________    ________
f.   Mutual Funds                       1  2  3  ________    ________
g.   Variable Annuities                1  2  3  ________    ________
h.   Common Stocks                  1  2  3  ________   ________
i.   Real Estate                           1  2  3  ________    ________
j.   Tax Shelters (oil, cattle, etc) 1  2  3  ________    ________
k.   Other (specify)                    1  2  3  ________    ________
2. From the following list, indicate the five items you consider most important in your personal financial management program
using five as most important and one as least important:
 _____a.  Liquidity (availability of cash when needed)
 _____b.  Current Income
 _____c.  Future Income
 _____d.  Inflation Protection (assuring purchasing power)
 _____e.  Income Tax Deferral/Relief
 _____f.  Capital Growth
 _____g.  Safety of Principal

3. In the handling of your finances, would you be willing to take above-average risks in order to seek greater growth? _____Yes    _____No
If yes, indicate what percent of your investable funds you would be willing to place in investment of above-average risk._____%

 

    The rest of the inventory consists of names, addresses and the location of various papers you may have. To exemplify the importance  of recording such information (whether by video or in writing) the following suggestion is
given:  

 

Write a "Testamentary Letter"
    While it may not be legally binding, a testamentary letter can be a great help to survivors in understanding your wishes. The following types of information could be included:
   - Your objectives for the estate (ex: "Don't sell the business")     

   - Preferences about your burial arrangements, funeral or memorial        services, organ donation, etc.
   - Location of important papers and safety deposit boxes, etc.
   - Location of bank accounts and statements
   - Names and addresses of advisors
   - Names and addresses of people to be advised of your death, both for friendship's sake and business needs
   - List of credit cards and other loans
   - Information on monthly bills
   - Location of vehicle registration
   - Tax returns and other tax information
   - Names of dependents and their needs; also of other inheritors
   - Opinions on how you think the family finances should be handled, and by whom
   - Home deed and mortgage information
   - Pension and retirement plan information and whom to contact
   - Insurance information
   - Small Businesses, in order to properly take deductions, should be able to prove in their records the following deductibles:
 -Costs relating to:  vehicles, including mileage, gas, insurance,  parking and tolls, repairs, and maintenance expenses.
     -Interests paid on loans used for business purposes.
     -Items used in business, even if used privately as well:
       computer, video tape recorder, books, magazines, educational  audio and video tapes, calculator, typewriter, audio recorder, telephone and other equipment.

      Gift, travel, and entertainment receipts and club memberships

         Date:
______________________________________________________________________
Financial Advisor :Name           :(Area Code) Phone Number
            :________________________:________________________
    :Address
____________________:_________________________________________________
Attorney   :Name    :(Area Code) Phone Number         :________________________:________________________
    :Address
____________________:_________________________________________________
Banker   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Accountant  :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Employee Benefits :Name    :(Area Code) Phone Number
Representative  :________________________:________________________
    :Address
____________________:_________________________________________________
Doctor   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Clergy   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Other   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Other   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Other   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________
Other   :Name    :(Area Code) Phone Number     :________________________:________________________
    :Address
____________________:_________________________________________________

   Date:
______________________________________________________________________
Adoption Papers :
____________________:_________________________________________________
Automobile Title(s) :
____________________:_________________________________________________
Bank Books  :
____________________:_________________________________________________
Bank Statements :
____________________:_________________________________________________
Bills of Sale  :
____________________:_________________________________________________
Birth Certificate(s):
____________________:_________________________________________________
Canceled Checks :
____________________:_________________________________________________
Christening Records :
____________________:_________________________________________________
Contracts   :
                    :_________________________________________________
    :
____________________:_________________________________________________
Citizenship Papers :
____________________:_________________________________________________
Confidential Papers :      :_________________________________________________
Inventory continued:
____________________:_________________________________________________
Credit Cards  :     :_________________________________________________
    :
    :_________________________________________________
    :
____________________:_________________________________________________
Deeds   :
____________________:_________________________________________________
Diaries   :
____________________:_________________________________________________
Diplomas & Degrees :
____________________:_________________________________________________
Family Records  :
____________________:_________________________________________________
Guardianship Papers :
____________________:_________________________________________________
Historical Records :
____________________:_________________________________________________
Income Tax Records :     :_________________________________________________
    :
____________________:_________________________________________________
Insurance Policies :
____________________:_________________________________________________

______________________________________________________________________
Inventories-Business:      :_________________________________________________
    :
____________________:_________________________________________________
Keys    :
____________________:_________________________________________________
Legal Documents - :
Business____________:_________________________________________________
Legal Documents - :
Personal____________:_________________________________________________
Letters   :
____________________:_________________________________________________
Marriage Certificate:
____________________:_________________________________________________
Medical Records :
____________________:_________________________________________________
Military Service :
Records_____________:_________________________________________________

Mortgages   :
____________________:_________________________________________________
Notes   :
____________________:_________________________________________________
Passports   :
____________________:_________________________________________________

Pension Certificates:
____________________:_________________________________________________
Safe Deposit Box :
____________________:_________________________________________________
Securities  :
____________________:_________________________________________________
Social Security Cards_______________:_________________________________________________
Social Security Number(s)___________:_________________________________________________
Stock Certificates :
____________________:_________________________________________________
Tax Receipts  :
and Records  :_________________________________________________
(Other than Income Tax)_______________:_________________________________________________
Trust Papers  :
____________________:_________________________________________________
U.S. Savings Bonds :
____________________:_________________________________________________
Wills   :      ____________________:_________________________________________________