You are on page 1of 10

Client Name_____________

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

CLIENT NAME: GENDER: BIRTH DATE: STATE OF BIRTH


 _____________________________ ______  ____/____/____ _________
SPOUSE NAME: GENDER: BIRTH DATE: STATE OF BIRTH
 _____________________________ ______  ____/____/____ _________
ADDRESS:   __________________________________________________________ How long have you lived at this address?______
CITY, STATE, ZIP: ______________________________________________________ Who introduced you? _____________________
HOME  PHONE:  (_____) ______­ _________ EMAIL:   _______________________ NOTES:
CELL PHONE:    (_____) ______­ _________ EMAIL:   ______________________ __________________________
CELL PHONE:    (_____) ______­ _________ ANNIVERSARY:   _____/_____/_____ __________________________

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

1.  CPA:  _____________________ FIRM NAME: ______________________________  Who Introduced You?  ____________________


PHONE:  ( ____ ) ____­______ EMAIL: _______________ FAX        ( ____ ) ____­______ __________________________
ADDRESS:  ______________________________________________________________________________________
2.  ATTORNEY: __________________ FIRM NAME: ______________________________  Who Introduced You?  ____________________
PHONE:  ( ____ ) ____­______ EMAIL: _______________ FAX        ( ____ ) ____­______ __________________________
ADDRESS:  ______________________________________________________________________________________
3.  P&C AGENT: _________________ FIRM NAME: ______________________________  Who Introduced You?  ____________________
PHONE:  ( ____ ) ____­______ EMAIL: _______________ FAX        ( ____ ) ____­______ __________________________
ADDRESS:  ______________________________________________________________________________________
4.  MORTGAGE:  _________________ FIRM NAME: ______________________________  Who Introduced You?  ____________________
PHONE:  ( ____ ) ____­______ EMAIL: _______________ FAX        ( ____ ) ____­______ __________________________
ADDRESS:  ______________________________________________________________________________________
5.  ADVISOR / AGENT: ______________ FIRM NAME: ______________________________  Who Introduced You?  ____________________
PHONE:  ( ____ ) ____­______ EMAIL: _______________ FAX        ( ____ ) ____­______ __________________________
ADDRESS:  ______________________________________________________________________________________

CASH FLOW
INCOME
NOTES:
CLIENT/SPOUSE: TYPE:     MONTHLY:     ANNUAL : MODE: Do you expect annual increases in pay?_____
____________ SALARY $________________ $________________________ _______________ __________________________
____________ SALARY $________________ $________________________ _______________ __________________________
____________ BONUS  $________________ $________________________ _______________ __________________________
____________ BONUS $________________ $________________________ _______________ __________________________
____________ SELF­EMPLOYMENT $________________ $________________________ _______________ __________________________
____________ SELF­EMPLOYMENT $________________ $________________________ _______________ __________________________
____________ OTHER $________________ $________________________ _______________ __________________________

2
____________ 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

ESTIMATED MONTHLY SURPLUS: $ __________   How much does your savings account increase / decrease each month?   ______________________


BASIC MONTHLY EXPENSES:

Mortgage / Rent __________________ Do you have any large upcoming expenses? __________________________________________________


Property Taxes __________________
Insurance __________________
Utilities __________________
Groceries/Dining Out __________________ PLANNING COMMITMENT: $ ___________________   (Complete after Fact Finder)

Entertainment __________________
Debt Service __________________
Vacations __________________
LIABILITIES OWNER:         COMPANY:         LIABILITY: INTEREST RATE: MONTHLY PAYMENT:  TYPE:                       ORIGINATION DATE:
(NO TAXES / INSURANCE)

PRIMARY MORTG. A  /  B  /  JT.  __________ $__________ 


_________% $__________ ___________ ___________
SECONDARY MORTG. A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
LINE OF CREDIT A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
REAL PROPERTY A  /  B  /  JT.  __________ $__________     _________% $__________ ___________ ___________
CREDIT CARD A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
CREDIT CARD A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
AUTO LOAN A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
STUDENT LOAN A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
BUSINESS LOAN A  /  B  /  JT.  __________ $__________  _________% $__________ ___________ ___________
NOTES:

____________________________________________________________________________________________

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  /     

B  /  JT.  ________________ $________________  _________%      __________________________


BONDS A  / B / JT. 
     ________________
      $________________  _________%      __________________________ 529 PLAN / 
G.E.T. A  / B / JT. 
     ________________
      $________________  _________%      __________________________
ANNUITY A  / B / JT. 
     ________________
      $________________  _________%      FIXED / VARIABLE   _______________   

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  /     

B  /  JT.  ________________ $________________  _________%      __________________________


3
OTHER A  /  B  /  JT.  ________________ $________________  _________%      __________________________

QUALIFIED / RETIREMENT ASSETS

OWNER: ROTH? COMPANY / CUSTODIAN: VALUE: RATE OF RETURN: MONTHLY CONT.:  COMPANY MATCH: BENEFICIARY:


401(K)  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
401(K)  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
IRA  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
IRA  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
SIMPLE  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
SEP  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
403(B)  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
PENSION  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________
OTHER  A  /  B  ____ _______________ $_____________  _________%      $________%  $_________% ____________

PENSIONS (CREDIT BASED)

OWNER: COMPANY / CUSTODIAN: BEGINNING AGE: MONTHLY INCOME: COLA: SURVIVOR %: NOTES / FORMULA:


A  /  B  _____________ _________ $__________  ____%  ______% __________________________
A  /  B  _____________ _________ $__________  ____%  ______% __________________________

ESTATE
NOTES:

Do you currently have a will?  YES  NO Date last updated: _____ / 20____  Executor:  ____________________


Have any changes occurred since the last update of your will?  YES  NO  Changes:  _____________ __________________________
Do you have Guardianship established for your children?   YES  NO  Guardian(s):  ___________ __________________________
Do you have Health Care Directives and Power of Attorney?   YES  NO Who is PoA:  ___________ __________________________
Do you make gifts from your cash flow or assets?  YES  NO  Recipient(s): ___________ Annual Amount: $ ________________
Do you have a Revocable / Irrevocable Living Trust?   YES  NO  Beneficiaries: ___________ Trustee: _______________ Is it funded?  Y  /  N
Will you receive any income from a Trust or Inheritance?   YES  NO  Details: ______________ __________________________
To whom would you like to leave your assets? ________________________________________ __________________________

4
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.):

A  /  B Group / Personal   ____________ $__________    ________ _________ $______ _______________________


A  /  B Group / Personal   ____________ $__________    ________ _________ $______ _______________________
A  /  B Group / Personal   ____________ $__________    ________ _________ $______ _______________________
A  /  B Group / Personal   ____________ $__________    ________ _________ $______ _______________________
What is your current plan if you were disabled? __________________________________________________________________

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:

A  /  B Vehicle ____________ $___ / $____    $_______  YES  NO $______ _______________________


A  /  B Vehicle ____________ $___ / $____    $_______  YES  NO $______ _______________________
A  /  B Property ____________ $_________    $_______ N/A $______ _______________________
A  /  B Umbrella ____________ $_________    $_______  N/A $______ _______________________
A  /  B Umbrella ____________ $_________    $_______  N/A $______ _______________________
HEALTH QUESTIONS

Do you use tobacco or nicotine products? CLIENT A  YES  NO Date and frequency last used:  ____________________


CLIENT B  YES  NO Date and frequency last used:  ____________________
Are you currently taking any medications? CLIENT A  YES  NO Medications (& dosage): _______________________
CLIENT B  YES  NO Medications (& dosage): _______________________
Do you have any notable health issues? CLIENT A  YES  NO Health issues (& when diagnosed):   _________________
CLIENT B  YES  NO Health issues (& when diagnosed):   _________________

5
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 _________________

6
NOTES
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

7
Advisor List of Items to Do

1. ________________________________________________________________
________________________________________________________________

2. ________________________________________________________________
________________________________________________________________

3. ________________________________________________________________
________________________________________________________________

4. ________________________________________________________________
________________________________________________________________

5. ________________________________________________________________
________________________________________________________________

6. ________________________________________________________________
________________________________________________________________

7. ________________________________________________________________
________________________________________________________________

8. ________________________________________________________________
________________________________________________________________

9. ________________________________________________________________
________________________________________________________________

10. ________________________________________________________________
________________________________________________________________

11. ________________________________________________________________
________________________________________________________________

Client List of Items to Gather

8
1.

________________________________________________________________
________________________________________________________________

2.

________________________________________________________________
________________________________________________________________

3.

________________________________________________________________
________________________________________________________________

4.

________________________________________________________________
________________________________________________________________

5.

________________________________________________________________
________________________________________________________________

6.

________________________________________________________________
________________________________________________________________

7.

________________________________________________________________
________________________________________________________________

8.

________________________________________________________________
________________________________________________________________
9
9.

________________________________________________________________
________________________________________________________________

10.________________________________________________________________
________________________________________________________________

11.________________________________________________________________
________________________________________________________________

10