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Date__________
CONFIDENTIAL
Planning Your Financial Future
Securities and Investment Advisory Services offered exclusively through Hornor, Townsend & Kent, Inc., a Registered
Investment Advisor, member FINRA/SIPC. Pacific Capital Resource Group, Inc. is independent of Hornor, Townsend &
Kent, Inc. and is a licensed insurance agency – 10900 NE 8th Street – Suite 1550, Bellevue, WA 98004 –
(425) 6418788 – A4YK061301E2
FINANCIAL ADVISOR _____________________________ DATE: ______/______/_______
PERSONAL DATA
FAMILY / DEPENDENTS
NAME: GENDER: AGE: BIRTH DATE: DEPENDENT OF: _______________________________________
______________________ _____ _____ _____/_____/_____ A B __________________________
______________________ _____ _____ _____/_____/_____ A B __________________________
______________________ _____ _____ _____/_____/_____ A B __________________________
______________________ _____ _____ _____/_____/_____ A B __________________________
______________________ _____ _____ _____/_____/_____ A B __________________________
Do you plan on having any / additional children? ______________________________________ __________________________
OCCUPATION
CLIENT JOB TITLE: ______________________________________________________ Number of years with employer?_____________
EMPLOYER: __________________________________________________________ __________________________ ADDRESS:
___________________________________________________________ __________________________
SPOUSE JOB TITLE: ______________________________________________________ Number of years with employer?_____________
EMPLOYER: __________________________________________________________ __________________________ ADDRESS:
___________________________________________________________ __________________________ Do you see a substantial change in your income in
the next two years? ______________________________________________________
How long do you plan on staying with your current employer? __________________________________________________________
ADVISORS
CASH FLOW
INCOME
NOTES:
CLIENT/SPOUSE: TYPE: MONTHLY: ANNUAL : MODE: Do you expect annual increases in pay?_____
____________ SALARY $________________ $________________________ _______________ __________________________
____________ SALARY $________________ $________________________ _______________ __________________________
____________ BONUS $________________ $________________________ _______________ __________________________
____________ BONUS $________________ $________________________ _______________ __________________________
____________ SELFEMPLOYMENT $________________ $________________________ _______________ __________________________
____________ SELFEMPLOYMENT $________________ $________________________ _______________ __________________________
____________ OTHER $________________ $________________________ _______________ __________________________
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____________ ANNUITY $________________ $________________________ _______________ __________________________
____________ RENTAL PROPERTY $________________ $________________________ _______________ __________________________
____________ SOCIAL SECURITY $________________ $________________________ _______________ __________________________
GROSS INCOME $________________ $________________________ Do you usually get a tax refund?________
NET INCOME $________________ $________________________ __________________________
__________________________
TAXES __________________________
TAXES PAID LAST YEAR: ____________ $________________________ __________________________
TAX REFUND: ____________ $________________________ __________________________
Do you pay Quarterly Estimated Taxes? YES NO __________________________
EXPENSES
FIXED: VARIABLE: TOTAL:
MONTHLY EXPENSE ESTIMATE: $ __________ + $ __________ = $ _____________ DETAILED EXPENSE REPORT ATTACHED? Y / N
Entertainment __________________
Debt Service __________________
Vacations __________________
LIABILITIES OWNER: COMPANY: LIABILITY: INTEREST RATE: MONTHLY PAYMENT: TYPE: ORIGINATION DATE:
(NO TAXES / INSURANCE)
____________________________________________________________________________________________
SAVINGS & GROWTH
ASSETS OWNER: COMPANY / CUSTODIAN: VALUE: RATE OF RETURN: NOTES:
CHECKING ________________
A / B / JT. $________________ _________% __________________________
CHECKING ________________
A / B / JT. $________________ _________% __________________________
SAVINGS ________________
A / B / JT. $________________ _________% __________________________
MONEY MARKET ________________
A / B / JT. $________________ _________% __________________________
CD ________________
A / B / JT. $________________ _________% __________________________
MUTUAL FUNDS ________________
A / B / JT. $________________ _________% __________________________
MANAGED ACCOUNT ________________
A / B / JT. $________________ _________% __________________________ STOCKS A /
RESIDENCE A / B / JT.
________________
$________________ _________% __________________________
REAL PROPERTY A / B / JT.
________________
$________________ _________% RENTAL INCOME: ________________ BUSINESS
A / B / JT.
________________
$________________ _________% STRUCTURE / OWNERSHIP: ___________
PARTNERSHIPS A / B / JT.
________________
$________________ _________% __________________________ VEHICLES
A / B / JT.
________________
$________________ _________% __________________________ ART /
COLLECTIBLES A / B / JT.
________________
$________________ _________% __________________________ VEHICLES
A / B / JT.
________________
$________________ _________% __________________________ OTHER A /
QUALIFIED / RETIREMENT ASSETS
PENSIONS (CREDIT BASED)
ESTATE
NOTES:
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PROTECTION
LIFE INSURANCE
TYPE: INSURED: CARRIER: BENEFICIARY: DEATH BENEFIT: PREMIUM: CASH VALUE: SURRENDER: ISSUE DATE: REMAINING TERM:
TERM A / B / SURV. ____________ ________ $_________ $_____ $_______ $_______ ______ ___________
TERM A / B / SURV. ____________ ________ $_________ $_____ $_______ $_______ ______ ___________
WHOLE A / B / SURV. ____________ ________ $ _________ $ _____ $ _______ $_______ ______ ___________
WHOLE A / B / SURV. ____________ ________ $_________ $_____ $_______ $_______ ______ ___________
UL A / B / SURV. ____________ ________ $ _________ $ _____ $ _______ $_______ ______ ___________
UL A / B / SURV. ____________ ________ $_________ $_____ $_______ $_______ ______ ___________
How did you arrive at the amount of life insurance that you have? ________________________________________________________
When did you buy your last policy? From whom did you buy it?__________________________________________________________
What is your current plan if you passed away? ___________________________________________________________________
DISABILITY INSURANCE
INSURED: TYPE: CARRIER: MONTHLY BENEFIT: ELIM. PERIOD: BENEFIT PERIOD: PREMIUM: NOTES (COLA, OWN OCC., ETC.):
LONGTERM CARE INSURANCE
INSURED: TYPE: COMPANY: MONTHLY BENEFIT: ELIM. PERIOD: BENEFIT PERIOD: PREMIUM: NOTES:
_______ ________ ________________ $_______________ ____________ _____________ $_____________ __________________________
_______ ________ ________________ $_______________ ____________ _____________ $_____________ __________________________
_______ ________ ________________ $_______________ ____________ _____________ $_____________ __________________________
_______ ________ ________________ $_______________ ____________ _____________ $_____________ __________________________
Have you or anyone in your family ever experienced a longterm care need? ___________________________________________________
How would it affect you and your family if you had a longterm care need tomorrow? ______________________________________________
Will you be caring for elderly parents? _______________________________________________________________________
PROPERTY & CASUALTY INSURANCE
INSURED: TYPE: CARRIER: LIABILITY LIMITS: DEDUCTIBLE: UN/UNDERINSURED: PREMIUM: NOTES:
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FINANCIAL GOALS
EMERGENCY RESERVES
NOTES:
What do you feel is an adequate amount of liquid cash reserves to meet unforeseen emergencies? $___________ __________________________
EDUCATION
How do you feel about saving for your children’s college education? ______________________________________________________
NAME: SCHOOL: # YEARS AMOUNT
_________________ ___________ _____ FULL RIDE ___________________ __________________________
_________________ ___________ _____ FULL RIDE ___________________ __________________________
_________________ ___________ _____ FULL RIDE ___________________ __________________________
_________________ ___________ _____ FULL RIDE ___________________ __________________________
DISABILITY
Please describe what you would like to have happen in the event you got sick or hurt. ______________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Desired Monthly Income: $ __________________________________________________ __________________________
If you could not work, how long would you be able to live from savings?__________________________ __________________________
LONGTERM CARE
Please describe what you would like to have happen in the event you could no longer care for yourself. ____________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Desired Daily Benefit: $ ______________________________________________________________________________
How would the additional expense of longterm care costs affect your savings? _________________________________________________
RETIREMENT
Please describe what you would like your retirement picture to look like. _____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Where would you like to live? ___________________________________________________________________________
Compared to your current standard of living, would you like your retirement to be the same, better, or less? _________________________________
Desired Retirement Age: CLIENT _______ SPOUSE _______ Monthly Inc. Need: $ ________ __________________________
Life Expectancy: CLIENT _______ SPOUSE _______ Inflation: _________% __________________________
Social Security: CLIENT _______ SPOUSE _______ EXP. ROR _________% __________________________
SURVIVOR
Please describe what you would like to have happen in the event of a premature death. ______________________________________________
If you passed prematurely:
Would you want your spouse / dependants to be able to service your debt and maintain their current lifestyle? YES NO _________________
Would you want your spouse to be able to achieve the retirement lifestyle that you envisioned? YES NO _________________
Would you want to be able to pay for your children’s college? YES NO _________________
Regardless of when you pass:
Do you want to leave a legacy to either your dependants or a charity? YES NO _________________
Would you want to pass your assets on in the most taxefficient manner possible? YES NO _________________
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NOTES
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Advisor List of Items to Do
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Client List of Items to Gather
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