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Contact Information Client Spouse First Name

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53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 1
Contact Information
Client Spouse
First Name
Last Name
Birth Date ______/______/________ ______/______/________
Phone ( ) - ( ) -
Email
Street Address
City, State, Zip
Professional Contact Information
Profession Name Email Address Telephone
Accountant ( ) -
Estate Planning Attorney ( ) -
Other Information
Question Yes No Updated
Do you own health insurance?
______/______/________
Do you own disability insurance?
______/______/________
Have you named your beneficiaries?
______/______/________
Do you have a will?
______/______/________
Do you have a trust?
______/ _____/________
PLEASE CHOOSE THE CLIENTS TAX FILING STATUS
SINGLE
HEAD OF HOUSEHOLD
MARRIED
Client Data Form
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 2
Family Information
Name Relationship Date of Birth Spouse’s Name
______/______/________
______/______/________
______/______/________
______/______/________
Goals
Date Description
______/______/________
______/______/________
______/______/________
______/______/________
Notes
Date Description
______/______/________
______/______/________
______/______/________
______/______/________
Beneficiary Information
Name Relationship Date of Birth Address
______/______/________
______/______/________
______/______/________
______/______/________
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 3
Software Tab 2 - Assets
Retirement Assets
Owner Company
Tax
Classification
IRA, 401k, etc
Investment
Vehicle
CD, Bond etc
Allocation
Account
Value
Monthly
Contributions
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Software Tab 1 - Income
Employment Income
Client 1 Client 2
Employer
Current Gross Monthly Salary $ $
Projected Annual Salary Increase % % %
Projected Retirement Date
______/________ Retired
_____/________ Retired
Social Security Benefits
Owner Strategy Start Age Life or End Age
Gross Monthly
Benefit
Projected
COLA
Life or
$ %
Life or
$ %
Life or
$ %
Pension or Employer Sponsored Retirement Plan
Owner Description Start Age Life or End Age
Gross
Monthly
Benefit
Projected
COLA
% to
Survivor
Life or
$ % %
Life or
$ % %
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 4
Retirement Assets Continued
Owner Company
Tax
Classification
IRA, 401k, etc
Investment
Vehicle
CD, Bond etc
Allocation
Account
Value
Monthly
Contributions
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Low Risk
At Risk
$ $
Additional Assets
Owner Company Description Value
Single Premium Annuities
Owner Company
Tax
Classification
Payout Mode
Initial
Account
Value
Benefit
Amount
Benefit
Start Date
Benefit
End Date
Single
Joint
Monthly
Annual
$ $ ____/____
Life or ___/____
Single
Joint
Monthly
Annual
$ $ ____/____ Life or ___/____
Income Benefit Annuities
Owner Company
Tax
Classification
Payout
Payout
Mode
Account
Value
Benefit
Amount
Benefit
Start Date
Benefit
End Date
Single
Joint
Monthly
Annual
$ $ ____/____
Life or ___/____
Single
Joint
Monthly
Annual
$ $ ____/____
Life or ___/____
Single
Joint
Monthly
Annual
$ $ ____/____
Life or ___/____
Portfolio Information
Amount
Projected Before Retirement Rate of Return %
Projected After Retirement Rate of Return %
Minimum Retirement Funds $
Desired Risk Level (Please reference the Risk Assessment Questionnaire below) %
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 5
Software Tab 2 – Risk Assessment Button
EMERGENCY FUNDS – What dollar amount would you like in liquid or emergency funds?
TIME HORIZON - How much time, in years, can you let your Assets Earmarked for Retirement
grow, before you will have to begin withdrawals?
Points
0-2 Years 0
3-5 Years 1
6-10 Years 2
10+ Years 3
13+ Years 4
Answers to this question will help us determine how long you might leave your money before
having to use it in retirement.
Total Points
APPROACH TO SAVINGS & RISK – How do you feel about Saving and Risk?
Points
I do not want to see my principal amount decrease.
0
I cannot afford a significant loss to principal regardless of interest earned.
1
As long as my rate of interest stays ahead of inflation, I don’t want the exposure to non -
guaranteed financial products.
2
If I can make a moderate rate of interest on my money, I can withstand some fluctuation.
3
I want the potential for higher returns and I am willing to take on some risk.
4
Answers to this question will help us determine your tolerance for risk.
Total Points
INTEREST EARNING - What would you consider reasonable interest earned on your assets
earmarked for retirement?
Points
3% - 4%
0
4% - 6%
1
7% - 9%
2
9% - 11%
3
Greater than 11%
4
Answers to this question will help us determine your expectations for interest earned.
Total Points
RISK TOLERANCE – You’ve just made a $100,000 investment. You are exposed to the following
best and worst-case scenarios. Which possibility would you choose?
Points
Best Case = $102,000 Increase = 2,000 Worst Case = $100,000 Decrease = $0 0
Best Case = $104,000 Increase = 4,000 Worst Case = $96,000 Decrease = $4,000 1
Best Case = $108,000 Increase = $8,000 Worst Case = $92,000 Decrease = $8,000 2
Best Case = $112,000 Increase = $12,000 Worst Case = $88,000 Decrease = $12,000 3
Best Case = $116,000 Increase = $16,000 Worst Case = $84,000 Decrease = $16,000 4
Answers to this question will help us determine your risk tolerance. Total Points
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 6
Software Tab 3 - Expenses
Monthly Expenses
Current Monthly Expenses After Tax Projected Inflation Rate
$ %
Advanced Monthly Budget Worksheet
Household
Description Monthly Amount Inflation % Start Date End Date
Mortgage Principal & Interest
$
%
___/____
Life or ___/____
Real Estate Taxes
$
%
___/____
Life or ___/____
Homeowners Insurance $ % ___/____
Life or ___/____
Home Equity Loan
$
%
___/____
Life or ___/____
Association Dues
$
%
___/____
Life or ___/____
Rent $ % ___/____
Life or ___/____
Renters Insurance
$
%
___/____
Life or ___/____
Utilities – Gas – Electric
$
%
___/____
Life or ___/____
Water – Sewer $ % ___/____
Life or ___/____
Cable – Phone – Internet
$
%
___/____
Life or ___/____
Maintenance & Improvement
$
%
___/____
Life or ___/____
House Cleaning
$
%
___/____
Life or ___/____
Daily Living
Description
Monthly Amount
Inflation %
Start Date
End Date
Food
$
%
___/____
Life or ___/____
Dining Out
$
%
___/____
Life or ___/____
Clothing
$
%
___/____
Life or ___/____
Personal Care
$
%
___/____
Life or ___/____
Healthcare & Insurance
Description
Monthly Amount
Inflation %
Start Date
End Date
Health Insurance $ % ___/____
Life or ___/____
Prescriptions
$
%
___/____
Life or ___/____
Life Insurance
$
%
___/____
Life or ___/____
Long Term Care Insurance $ % ___/____
Life or ___/____
Disability Insurance
$
%
___/____
Life or ___/____
Veterinarian
$
%
___/____
Life or ___/____
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 7
Transportation
Description
Monthly Amount
Inflation %
Start Date
End Date
Auto Loans
$
%
___/____
Life or ___/____
Auto Insurance
$
%
___/____
Life or ___/____
Fuel
$
%
___/____
Life or ___/____
Repairs
$
%
___/____
Life or ___/____
Debt & Obligations
Description
Monthly Amount
Inflation %
Start Date
End Date
Credit Cards $ % ___/____
Life or ___/____
Tuition – Student Loans
$
%
___/____
Life or ___/____
Alimony
$
%
___/____
Life or ___/____
Child Support $ % ___/____
Life or ___/____
Entertainment
Description Monthly Amount Inflation % Start Date End Date
Parties & Events
$
%
___/____
Life or ___/____
Sports – Hobbies – Lessons
$
%
___/____
Life or ___/____
Membership Dues
$
%
___/____
Life or ___/____
Vacation & Travel
$
%
___/____
Life or ___/____
Miscellaneous
Description
Monthly Amount
Inflation %
Start Date
End Date
Charitable Donations
$
%
___/____
Life or ___/____
Gifts
$
%
___/____
Life or ___/____
Other
$
%
___/____
Life or ___/____
Liabilities
Owner Company Description Value
Future Cash Flows
Owner Description Mode Type Taxation Amount
%
Change
Start Date End Date
Annual
Monthly
Outflow
Inflow
Taxable
Non-Taxable
$ % ____/______ ____/______
Annual
Monthly
Outflow
Inflow
Taxable
Non-Taxable
$ % ____/______ ____/______
Annual
Monthly
Outflow
Inflow
Taxable
Non-Taxable
$ % ____/______ ____/______
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 8
Software Tab 6 – Red Line Solves Button
The analysis may show you running out of money during retirement. If this were to occur, how would you rank taking
the following steps to help alleviate the red line? Use a scale of 1-6 where 1 would be the most desirable step and 6
the least desirable step.
Red Line Solutions Steps – Rank from 1-6 Ranking
Retire at a later date.
Work a second or part time job after retirement.
Reduce monthly expenses.
If not yet retired, increase contributions to retirement savings.
Reverse mortgage.
Look for other income alternatives.
Software Tab 8 – Long Term Care
Existing Long-Term Care Coverage Information
Owner Company Type Start Date
Daily
Benefit
Years
Inflation
Type
Inflation
%
Monthly
Premium
Cash
Reimbursement
____/____/____ $
Simple
Compound
% $
Cash
Reimbursement
____/____/____ $
Simple
Compound
% $
Software Tab 7 – Life Insurance
Health Information
Client Smoker Health Concerns
Yes
No
Yes No
Existing Life Insurance Information
Owner Company Type
Death
Benefit
Monthly
Premium
Cash
Value
Policy End Date
Term
Permanent
$ $ $
Life or ____/______
Term
Permanent
$ $ $
Life or ____/______
Term
Permanent
$ $ $
Life or ____/______
53602 Client Initials __________ Client Initials__________ Agent Initials___________ Date __________ 9
I hereby attest that the information on this Client Data Form has been provided by me and to the best
of my knowledge is accurate. I further understand that the information provided will be used with your
retirement software to create my retirement analysis. I understand fixed-only licensed insurance agents
may not suggest the sale of an insurance product based upon the sale or liquidation of securities
products. Proper registered registrations are required for such recommendations and sales. The
information gathered with this form will be used for the sole purpose of helping create a financial
strategy for your retirement. The financial professional providing the analysis does not provide tax or
legal advice. Prior to making any financial decisions consumers should obtain tax or legal advice from a
qualified professional.
Client: ____________________________________________ Date: _____________________
Client: ____________________________________________ Date: _____________________
Agent: ____________________________________________ Date: _____________________
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Contact Information Client Spouse First Name

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Completed 15 September 2021

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