| Client and Spouse Information |
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Client |
Spouse |
| Gender: |
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| Age: |
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| Retirement Age: |
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| First To Die: |
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| Child Information |
| Number of Children: |
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Child 1: Age
Education Years
Annual Cost $
Child 2: Age
Education Years
Annual Cost $
Child 3: Age
Education Years
Annual Cost $
Child 4: Age
Education Years
Annual Cost $
Child 5: Age
Education Years
Annual Cost $
Child 6: Age
Education Years
Annual Cost $
Child 7: Age
Education Years
Annual Cost $
Child 8: Age
Education Years
Annual Cost $
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| Income Information |
| Income: |
$ |
$ |
| Other Income (combined): |
$ |
% of current income during Dependency Period:
Enter a percentage of the total current income the family needs to
maintain their current lifestyle while there are dependent children to support.
75% or more is recommended. |
% |
% of current income during Empty Nest Period:
Enter the percentage of the total current income the survivor needs in
the empty nest period. This is the period between the time when there are no
longer any dependent children to support and when retirement starts. With no
children to support during this period, the percentage of current income needed
could be reduced. 60% is recommended. |
% |
% of current income during Retirement Period:
Enter the percentage of the total current income the survivor needs
during the retirement period. 60% is recommended. |
% |
| Include Social Security as a Retirement Benefit: |
Yes
No |
| Assets Information |
Life Insurance Proceeds to Survivor:
Enter the total death benefit from life insurance plans (personal and
group) that will be paid to the survivor at the death of the first to die. |
$ |
Survivor's Working Years Income:
Enter the amount of potential annual survivor’s earned income
during the working years. If the survivor does not anticipate any change in
employment (for example, from part time to fulltime) enter the same amount as
in the spouse’s current annual income field. |
$ |
Survivor's Retirement Years Income:
Enter any income from part time employment, rental property income,
etc. DO NOT include Social Security benefits, they are calculated by the
program. Also, do not include any income, interest or dividends generated by
the items listed under Savings & Investments. |
$ |
| Cash, Savings, CD's: |
$ |
| Pension, IRA, 401(k), ESOP: |
$ |
| Securities (stock, bond, mutual funds): |
$ |
Real Estate Equity:
Enter the net equity (market value minus mortgage balance) of real estate
that will be liquidated upon the death of the first to die. If the property
will be retained for income or is used as the primary residence, DO NOT include
it in this field. |
$ |
Other Assets:
Enter the total current value of any assets not previously listed
that would not be retained.
Some examples are personal property and business interests.
|
$ |
Assumed rate of return (net of inflation & taxes):
Enter an assumed rate of return on capital. Take a
reasonable interest rate and subtract from it an expected long term
inflation rate. This rate could be further reduced to reflect taxes, if
so desired. This rate is used to figure present value
of future money. |
% |
| Expense Information |
Final
Expenses:
Enter the amount needed to cover probate costs, burial costs, final
medical bills for the first to die, other estate administrative costs, state
death taxes, and federal estate taxes. Final expenses will generally total
$5,000 to $20,000 for most families. This can be calculated as a percentage of
the prospect’s assets (5-7%) or a percentage of annual income (25-40% may
be appropriate). |
$ |
Debt/Loan Repayment:
Enter the sum of all outstanding account balances excluding the home
mortgage or monthly rent. Include car loans, home improvement loans, credit
card balances, education loans, etc. |
$ |
Mortgage Balance/Rent Fund:
Enter the current mortgage balance on the primary residence only. For
renters, calculate a home assurance fund. (Multiply the monthly rent payment by
12 to get an annual figure and then divide that by the assumed rate of return.
This provides the amount of capitol required to generate enough interest to
cover the monthly rent.) |
$ |
Emergency Fund:
Enter the amount to be set aside in a reserve fund. It is recommended that
30-50% of one year’s income which for most families, would require a
minimum of $10,000 to $25,000. This fund guards against unexpected events such
as a job loss, a short term illness that interrupts the survivor’s
income, a major home or car maintenance problem, etc. |
$ |
Special Considerations:
Enter the amount to be used for unique expenses such as the care of
dependent parents, disabled or handicapped children, or a charitable gift to a
favorite church, school or organization. |
$ |