A Confidential
Financial and Retirement
Planning
Fact Finder
For
Today’sDate
The Guardi
anLi
fe Insurance Companyof Ameri
ca,New York,NY 10004
Pub3497A
Page 1 of 17
Client 1 Today’s Date
Name Date of Birth
Address City State/Zip
Phone (Home) SocialSecurity #
Phone (Office) email
Phone (Other) Fax
Occupation Length of Service Plans to Change?
Office/W ork Address City State/Zip
Height W eight Smoker? Ever smoke? Heal th Status
Parents Living? Expecting an Inheritance?
Client 2
Name Date of Birth
Address City State/Zip
Phone (Home) SocialSecurity #
Phone (Office) email
Phone (Other) Fax
Occupation Length of Service Plans to Change?
Office/W ork Address City State/Zip
Height W eight Smoker? Ever smoke? Heal th Status
Parents Living? Expecting an Inheritance?
Children
Name Date of Birth Spouse
Name Date of Birth Spouse
Name Date of Birth Spouse
Name Date of Birth Spouse
Name Date of Birth Spouse
Grandchildren
Names
Are al
lof the chil
dren l
isted of this marriage? If no, pl
ease expl
ain
W oul
d you l
ike to provide for anyone el
se?(i.
e.el
derl
y parents/famil
y members)
Any specialconsiderations? Famil
y members with specialneeds?
Do you have any of the fol
lowing?
Cl
ient1 Cl
ient2 Type Date Drafted
W il
l
Trust(s)
Power of Attorney
Heal thcare Proxy/Living W il
l
Safe DepositBox XXXXXXXXX XXXXXXXXX
W here? XXXXXXXXX XXXXXXXXX
Other Advisors
CPA Phone
Attorney Phone
InvestmentManager Phone
FinancialPlanner Phone
Insurance Agent Phone
TrustOfficer Phone
Page 2 of 17
ASSETS
Cash/Cash Equivalents (Savings,Checking,M oney M arkets,CDs,Savings Bonds)
M onthly Interest
Owner Type Institution Balance Additions Rate M aturity
Are any of these earmarked for a specific purpose?
Stocks/StockM utual Funds
Balance/ M onthly Growth
Owner Company/Fund Basis Additions Dividends Rate
Are any of these earmarked for a specific purpose?
Bonds/Bond M utual Funds
Company/ M onthly
Owner Fund Type Balance Additions Income Yield M aturity
Are any of these earmarked for a specific purpose?
Real Estate
M arket
Owner Location Value Type/Purpose Income Basis M ortgage
Page 3 of 17
Retirement Plans
Monthly Employer Growth
Owner Type Balance Company Contribution Match Rate Bene.
Annuities
Owner/ Monthly Growth Contract
Annuitant Company Balance Contribution Rate Date Type Bene.
Other (Cars, Boats, Collectibles, H ome Furnishings)
Owner Value Asset Name Purpose
Page 4 of 17
LIABILITIES
Mortgages (1st or 2nd mortgage, home equity loan/line of credit)
Owner/ Monthly Interest Loan Loan
Debtor Location Bank Balance Payment Rate Term Date
Credit Cards
Owner/ Monthly Company/ Interest Loan Loan
Debtor Balance Payment Bank Rate Term Date
Personal Loans (Student, Car, Boat)
Owner/ Monthly Company/ Interest Loan Loan
Debtor Balance Payment Bank Rate Term Date
Page 5 of 17
INDIVIDUAL INSURANCE
Life Insurance Policies
Owner/ Face Cash Contract Policy
Insured Company Amount Premium Value Date Loans Type Bene.
Disability Policies
Annual Monthly Elim. Benefit Inflation Definition of
Owner Company Premium Benefit Period Period Rider? Disability
Long Term Care Policies
Annual Daily Elim. Benefit Inflation Services
Owner Company Premium Benefit Period Period Rider? Offered
Page 6 of 17
OTHER INSURANCE
Auto Policies
Company Covered Item Premium Deductible Coverage
Home Owners/Apartment Policies
Company Covered Item Premium Deductible Coverage
Umbrella Policies
Company Covered Item Premium Deductible Coverage
Personal Liability Policies
Company Covered Item Premium Deductible Coverage
Page 7 of 17
FIXED EXPENSES Monthly Annually
Mortgage/Rent/Condo Fee
Property Taxes
Homeowner’ s Insurance
Liability Insurance
Car Payments
Car Insurance
Gas/Oil/Maintenance
Commuting Costs
Parking/Garage
Tolls
Subway/Railroad
Telephone
Cellular
Fax
Pager
Internet
Electricity
Gas/Oil
Water/Sewer
Appliance Repair/Replacement
Home Maintenance/Repair/Improvements
Child Care:Diapers/Formula
Day Care
Groceries
Clothing/Laundry/Dry Cleaning
Housekeeping
Furnishings
Gifts:Birthdays/Holidays/Special Occasions
Life Insurance
Medical/Dental Expenses
Prescriptions/Eyewear
Health Insurance
Disability Insurance
Alimony/Child Support
Charity/Tithes
Ongoing Savings/Investments
Tuition
Books/Fees/Travel
Other Fixed
Professional Fees:Attorney/Accountant
Union Dues
Total Fixed
Page 8 of 17
DISCRETIONARY EXPENSES Monthly Annually
Vacation/Holidays
Entertainment/Recreation
Movies
Concerts
Theater
Music
Dining Out
Cable TV/Video Rentals
Computer Equipment
Education/Self Development
Fitness
Sports
Other Hobbies
Magazines/Books/Newspapers
Personal Care
Lunch/Breakfast
Miscellaneous
Club Dues
Pets
Other Discretionary
Total Discretionary
Total Fixed
Total Expenses
Page 9 of 17
INCOME Monthly Annually
Salary (1)
Salary (2)
Salary (3)
Self Employment Income (1)
Self Employment Income (2)
Self Employment Income (3)
Unearned Income
Interest
Dividends
Trust Income
Income from Insurance (Disability, LTC)
Rents/Royalties
Social Security
Pensions
Alimony
Child Support
Total Income
Total Expenses
Discretionary Income (Inc. minus Expenses)
Page 10 of 17
FINANCIAL OBJECTIVES
W hich of the following is a priority for you:
Amount
Goal Needed W hen Current Savings Ongoing Savings
Education
Client 1
Client 2
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Home Purchase
Vacation/Second Home
Purchase
Car/Boat Purchase
Start a Business
Other Obj
ective(s)
Other Obj
ective(s)
Page 11 of 17
RETIREMENT PLANNING
Define what retirement means to you
When do you plan to retire?
Client 1 Client 2
How much monthly income will you need?
Have you recently (within the past 2 years) checked your projected Social Security benefit?
What is your projected benefit?
Client 1 Client 2
How much will you rely on Social Security for retirement income?
What are your other projected sources of income?
Pension
Single Life Joint/Survivor Lump Sum
Employee Company Benefit At What Age Benefit Amount
Client 1
Client 2
Client 1
Client 2
Client 1
Client 2
Client 1
Client 2
Client 1
Client 2
Client 1
Client 2
Inheritance
From who?
Amount
Trusts
Grantor
Amount
Type
Have you considered other sources of income?
Gifts?
Reverse Mortgage?
Sale of Business?
Page 12 of 17
QUALIFIED PLAN/IRA MINIMUM REQUIRED DISTRIBUTIONS
Have you begun taking PLAN 1 PLAN 2
distributions (required minimum
distributions or otherwise)?
Beneficiary(ies)
Relationship of Beneficiary(ies)
Beneficiary Date(s) of Birth
Have you begun taking PLAN 3 PLAN 4
distributions (required minimum
distributions or otherwise)?
Beneficiary(ies)
Relationship of Beneficiary(ies)
Beneficiary Date(s) of Birth
Have you begun taking PLAN 5 PLAN 6
distributions (required minimum
distributions or otherwise)?
Beneficiary(ies)
Relationship of Beneficiary(ies)
Beneficiary Date(s) of Birth
Page 13 of 17
AUTHORIZATION TO RELEASE INFORMATION
To:
Please provide any information in your possession that is asked for in connection with my business and/or estate
planning being conducted by .
Thank you for your prompt attention to this matter.
Sincerely,
/ /
Page 14 of 17
DOCUMENT CHECKLIST
In order to make the most effective use of our time together, please bring the following documents, if
applicable, to our next meeting.
Investment Statements
Savings/Checking Account Statements
Pay Stubs (past two pay periods)
Employee Benefit Booklet
Employee Benefit Statement/Summary
Wills
Trusts
Powers of Attorney
Healthcare Proxy/Living Will
Real Estate Deeds
Tax Return (past two years)
Life Insurance Policies
Disability Insurance Policies
Long Term Care Insurance Policies
Property/Casualty Insurance Policies
Buy/Sell Agreement
Deferred Compensation/Split Dollar Agreement
Divorce/Prenuptial Agreements
Page 15 of 17
DOCUMENT RECEIPT
Investment Statements
Savings/Checking Account Statements
Pay Stubs
Employee Benefit Booklet
Employee Benefit Statement/Summary
Wills
Trusts
Powers of Attorney
Healthcare Proxy/Living Will
Real Estate Deeds
Tax Return (past two years)
Life Insurance Policies
Disability Insurance Policies
Long Term Care Insurance Policies
Property/Casualty Insurance Policies
Buy/Sell Agreement
Deferred Compensation/Split Dollar Agreement
Divorce/Prenuptial Agreements
I acknowledge receipt of the above-mentioned documents for review. They will be kept confidential and in a safe
area, and will be returned at our next meeting.
Financial Representative Signature
Client 1 Signature
Client 2 Signature
Date Signed
Page 16 of 17
LOCATION OF…
Will
Insurance Policies
Marriage License
Birth Certificates
List of Financial Accounts
Real Estate Deeds
Safe Deposit Box
Tax Returns
Buy/Sell Agreement
Stock/Bond Certificates
Outstanding Loan Documents
Funeral Arrangements
Page 17 of 17
