Fillable Advanced Planning Confidential Questionnaire - Personal Planning (New York Life)

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Advanced Planning Confidential Questionnaire - Personal Planning (New York Life)

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1. Client’s Name: __________________________________ Date of Birth: _____________ Male Female
State of Domicile: ____________ U.S. Citizen? Yes No (If No, list country: _____________________ )
Occupation: _____________________ Health: _____________ Smoker Non-Smoker
2. Spouse’s Name: _____________________________ ___ Date of Birth: ____________ Male Female
State of Domicile: ____________ U.S. Citizen? Yes No (If No, list country: _____________________ )
Occupation: _____________________ Health: _____________ Smoker Non-Smoker
3. Children & Other Beneficiaries:
* Children Grandchildren Other (please specify if from Prior marriage and/or Adopted)
** Single Married Divorced
4. If you or your spouse have been previously married, please list any children of the marriage(s) and describe any on-going
obligations:
Page 1 of 6
Name Age Relation*
Status
(S/M/D**)
Estimated
Income
Net Worth # of Children
Name: _____________________________ Agent
Code: ________ GO Name: _______
Advanced Planning Confidential
Questionnaire - Personal Planning
GENERAL INFORMATION
AGENT
2
nd
Agent: __________________________ Agent Code: ________ GO Name: _______
Phone (w): ______________________
Phone (c): ____________________
Highest Level of Council: ________________________
Year(s) Achieved:________
CA/AR Insurance License # (Required for all California/Arkansas Clients):_____________
Eagle IAR?:
Yes
No
Registered Rep.:
Yes
No
Agent Address: ________________________________________________________
Advanced Planning Confidential Questionnaire
Personal Planning
CURRENT PLANNING DOCUMENTS
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5. Clients’ Parents:
Living? Age Health
Dependent on You
for Support?
Potential
Inheritance?
Client’s Father
ο Yes ο No
ο Yes ο No
Client’s Mother
ο Yes ο No
ο Yes ο No
Spouse’s Father
ο Yes ο No
ο Yes ο No
Spouse’s Mother
ο Yes ο No
ο Yes ο No
6. Have you and your spouse lived in a Community Property state while married?
*Alaska is a Community Property state if parties voluntarily elect it
7. Estate Planning Documents: If your client or client’s spouse has any of the following documents, please enter the
requested details in the applicable sections.
Client
Will
Date: __/__/____ State: _____________
Terms: ☐ Simple ☐ Credit Shelter
☐ Pour-Over
Marital Deduction: ☐ Outright ☐ Trust
☐ QTIP
☐
DSUE, Amount _______
Date: __/__/____ State: _____________
Terms: ☐ Simple ☐ Credit Shelter
☐ Pour-Over
Marital Deduction: ☐ Outright ☐ Trust
☐ QTIP
DSUE, Amount _______
Revocable Trust
Date: __/__/____ State: _____________
Terms: ☐ Simple ☐ Credit Shelter
☐ Pour-Over
Marital Deduction: ☐ Outright ☐ Trust
☐ QTIP
☐
None
Date: __/__/____ State: _____________
Terms: ☐ Simple ☐ Credit Shelter
☐ Pour-Over
Marital Deduction: ☐ Outright ☐ Trust
☐ QTIP
None
Power of Attorney
Date: __/__/____ Date: __/__/____
Health Care
Proxy/Power
Date: __/__/____ Date: __/__/____
Living Will
Date: __/__/____ Date: __/__/____
Irrevocable Life
Insurance Trust
Date: __/__/____ Date: __/__/____
8. Please descr
ibe any pre-nuptial or post-nuptial agreements held by you or your spouse:
9. Other Documents:
10. Attorney: __________________________________ Telephone Number:
11. Accountant: ________________________________ Telephone Number:
12. Other Person: _______________________________ Telephone Number: _______________________________________
13. Which of the above advisors will participate in your planning?
14. Is he/she an Estate & Trust Specialist? ο Yes ο No
15. May we call him/her to discuss your planning with you on the line? ο Yes ο No
Page 2 of 6
☐
AK*
☐
AZ
☐
CA
☐
ID
☐
LA
☐
NM
☐
NV
☐
TX
☐
WA
☐
WI
Years____
Yes No
ADVISOR INFORMATION
Advanced Planning Confidential Questionnaire
Personal Planning
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16. Assets
Client(s) Name or Initials Agent Name
Market Value*
Cost B
asis
(if available)
Owner**
Growth Rate
(if different than overall
rate in Question #19)
Cash Equivalents:
Marketable Securities:
Residence(s):
Real Estate Investments:
Business Interests**:
Other Investments:
Antiques & Collectibles:
Personal Prop. & Autos:
*REQUIRED (estimation is acceptable)
**OWNER: H (Husband), W (Wife), J (Joint), TC (Tenants-In-Common), CP (Community Property), TO (Trust Officer)
17. Assets (cont’d) – Retirement Accounts & Annuities*
Current
Value
Basis
Owner/ Participant
Designated Beneficiary
TOTAL
*Please attach statement(s) if available & include type, e.g.: IRA, Roth IRA, SEP, SAR-SEP, TSA, Profit Sharing, Pension Plan,
401(k), Annuity, Non-Qualified Deferred Compensation, Non-Qualified Annuity, etc.
Page 3 of 6
FINANCIAL INFORMATION
Advanced Planning Confidential Questionnaire
Personal Planning
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18. Liabilities
Collateral
Principal
Balance
Interest
Rate
Maturity
Date
Total Annual
Payment
Loans:
Other Debts:
TOTAL
19. Net Worth is expected to grow at ____% per year (3% - 6% is customary). Or enter individual growth rate in Q16.
20. Client Preferenc
e for Estate Tax Computation: ο 0 growth ο 5 yrs ο 10 yrs ο 15 yrs ο 20 yrs (if under age 55)
21. List specific highly appreciating assets for potential transfer options:
_______________________________________________________________________________________________________
22. List any real estate owned outside the state or country, and its location (administration complexity): _____________
23. Life Insurance
Type
(e.g. WL, VUL,
Term, etc.)
Insurance
Provider
Owner Insured Beneficiary Keep?*
Cash
Value
Policy
Loan
Annual
Premium
Net Benefits
at Death
*Click if owner wants to keep/retain for cash value access (example: owner wants to retain his/her SLIRP for retirement income & does not wish to move the
policy to an ILIT or SLAT, due to complexity or significant cash value of the gift)
Totals
Total Assets: ............
- Total Liabilities: .......
= Net Worth: ................
+ Life Insurance: .........
= Taxable Estate: ........
Page 4 of 6
$
$
$
$
$
$
Advanced Planning Confidential Questionnaire
Personal Planning
Reset Page
24. How would you rate the general level of your investment knowledge?
Client: ☐ High ☐ Medium ☐ Low Spouse: ☐ High ☐ Medium ☐ Low
25. Annual Income
Client: (earned W-2 income) + (all other) = (total)
Spouse: (earned W-2 income) + (all other) = (total)
Total Gross Income:
Marginal Income Tax Rates: Fed. % State: % Net Annual Income:
26. How much discretionary income do you have? (net income exceeding lifestyle expenses)
27. Will your earnings/income change significantly over the next several years? If yes, please describe:
28. Please describe any significant financial events you foresee occurring in the next few years (i.e., sale of capital
assets, sale of home, IRA distributions, children entering college, parental care):
29. Planned age of retirem
ent: Client: ______ Spouse: ______ Why?_________________________
30. Pre-tax retirement income needed for lifestyle: $
31. What are your overall estate planning objectives? Is there anything you’d like to change in current plan?
32. Please mark any impor
tant planning needs / concerns:
☐ Long Term Care Needs ☐ Income Needs of Loved Ones ☐ Provide Special Care for Someone
☐ Provide Equally for Children ☐ Provide for Grandchildren ☐ Provide for Others (not descendants)
☐ Annual Exclusion Gifting ☐ Prior Taxable Gifts (if so, please note year and amount below)
☐ Charitable Gifting ☐ Low Basis Assets (Below 50%)
☐ Financial Concerns for Children/Others (spending, divorce, creditors, lifestyle, etc.)
Explanatory notes:
Page 5 of 6
CURRENT & FUTURE ESTATE PLANNING
$
Advanced Planning Confidential Questionnaire
Personal Planning
Reset All Pages
Submit to APG
Client(s) Name or Initials Agent Name
33. Describe any other i
ssues or concerns:
This material is provided for informational purposes only and is to be completed with information provided by the client. New York Life Insurance
Company, its agents and employees may not provide legal, tax or accounting advice. Individuals should consult their own professional advisors
before implementing any planning strategies. (c) 2016 New York Life Insurance Company. All rights reserved. SMRU 464845 (exp. 11.30.2022)
Page 6 of 6
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Completed 10 March 2021

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