PERSONAL FINANCIAL STATEMENT QUESTIONNAIRE

 

 

Client's name                                                                  Statement date                                  Prepared by                                        

 

 

CASH

 

1.  Record your checkbook or passbook balance in all bank accounts as of the financial statement date.

 

                                                                                                Statement       Restricted            Reconciled

Bank Name Account Title     Date Yes/No Balance H,W,J,C*

 

                                                                                                                                                $                                                   

                                                                                                                                                                                                     

                                                                                                                                                    

                                                                                                                                                                                                     

                                                                                                                                                $                     

* H - Husband W - Wife         J - Joint           C - Community Property

 

2.  Describe the nature of any restrictions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

 

 

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

 

MARKETABLE SECURITIES

 

1. Obtain or prepare a listing of marketable securities with the following information (or attach a separate listing if necessary).

 

                                                                                                           

            Name of      Date                  Cost                   Number            Current      

Security Acquired Basis of Shares   Value H,W,J,C,T

 

                                                                                                                                                                                                                                                                                                        

                                                                                                                                                                                                               

                                                                                                                                                                                                               

                                                                                                                                                                                                               

 

 

* H - Husband                         W - Wife            J - Joint    C - Community Property            T - Trust

 

 

3.  Determine if you have a cash balance with a broker.  If so, add this amount to cash or present as a separate

item after cash.                   $                      

 

 

4.  Determine whether you have a margin account.  Record this liability in the statement of financial condition.  $             

 

 

 

 

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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ACCOUNTS AND NOTES RECEIVABLE

                                                                                                Tax Basis

                                                                                                (if different                Cost Basis

                                                Due                 Interest           from principal (principal

Debtor's Name Date Rate to collect) to collect) H,W,J,

 

                                                                                                $                                  $                                        

                                                                                                                                                                                          

                                                                                                                                                                                          

                                                                                                                                                                                          

                                                                                                                                                                                                                                                                                           

 

                                                                                                            $                                  $                     

* H - Husband W - Wife         J - Joint          

 

Note any restrictions on these receivables.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

 

 

CASH VALUE OF LIFE INSURANCE POLICIES

 

 

Insurance Company    Date of Issue         Type of Policy            Name of Insured Owner of Policy

                                                                                         (whole life or term)                                                                                             

                                                                                                                                                                                                

                                                                                                                                                                                                           

                                                                                                                                                                                                

                                                                                                                                                                                                                                                                                                   

 

Annual Premium                                                        Current Face Amount Approximate Cash Value           Policy Loan

                                                                                                                                    (indicate if minimum deposit)

$                                 $                                      $                                              $                                                                                          

                                                                                                                                                                        

                                                                                                                                                                        

                                                                                                                                                                         

 

 

Note the coverage amount of insurance policies that name you as beneficiary.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

 

 

INVESTMENTS IN CLOSELY HELD BUSINESSES

 

1. Each investment in a separate entity should be included as one amount in the statement of financial condition. 

 

Name of Entity                                                                                                                                                                    

H,W,J*                                                                                                                                                                                                        

Type of Entity (C-Corp., S-Corp., Sole Prop.,                                                                                                                                 

                       Partnership, LLP, LLC)

 

* H - Husband W - Wife         J - Joint          

 

Percentage Ownership                       $                                        $                                              

Original Cost of Stock or Business Interest   $                                        $                                              

 

 

Please attach copies of statements that apply below:

 

Sole Proprietorship                            Corporation                                 LLC or LLP                                       Partnership               

   D.B.A. Certificate Copies of Stock Certificates Operating Agreement Partnership Agreement

 

 

 

 

 

 

RESIDENCE

                                                                                                                        Tax Basis

                                                                                    Approximate (cost plus                                Estimated

Address                                                                      Square Footage          improvements)                        Current Value

                                                                             $                       $                   

           

2.  Note how the estimated current value was determined.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

3.  Note the following information about mortgage liability on the residence:

 

                                                                                                                        Interest                       Monthly                      Mortgage      

Lien Holder                                                                Maturity Date            Rate                            Payment                     Liability

 

                                                                                                                                                %                     $                                          $                 

                                               

 

OTHER REAL ESTATE INVESTMENTS (INCLUDING LEASEHOLDS)

 

                                                                        Parcel #1        Parcel #2        Parcel #3                Total

Location and type                                                                                                                          

                                                                                                                                                         

Ownership %                                                                     %                   %                      %

Original Ownership Cost                                $                      $                      $                          $                

Current tax basis cost

  (negative tax basis of shelters)                      $                      $                      $                          $                

Monthly Income                                               $                      $                      $                          $                

Estimated current value                                   $                      $                      $                          $                

 

2.  Note how the estimated current value were determined.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

 

 

 

 

 

OTHER REAL ESTATE INVESTMENTS (INCLUDING LEASEHOLDS) Contd.

 

3.  Related debt:

 

                                                            Parcel #1        Parcel #2        Parcel #3        Total

Lienholder's name                                                                                                              

Original ownership cost                      $                      $                      $                      $                      

Monthly Payment                                 $                      $                      $                      $                      

Interest rate                                                           %                    %                      %                         %

Current debt balance                                       $                      $                      $                      $                      

 

 

 

OIL & GAS INTERESTS

                                                                                                                                                Cost (or tax

                                                                                                                                                basis, if                       Estimated

                                                                                                                                                different)                    Current Value

Location and                          Fractional            Developed or                        Annual                 of Fractional                        of Fractional

Description                  Interest      Undeveloped?      Income            Interest            Interest

                                                                                                                                                              %                                $                            $                                $                   

                                                                                                                                                                                                                  

                                                                                                                                                                                                                  

                                                                                                                                                                                                                  

 

                                                                                                                                                                                                                                                                                                                        $                                  $                   

 

2.  Describe how the estimated current values were determined.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

 

 

 

 

 

 

 

 

 

VESTED INTERESTS IN PENSION/PROFIT SHARING PLANS

 

 

                                                                                    Tax Basis                                Market

                                                                                    (balance of                             Value

                                                                                    individual's                             (vested

Descriptions                                                               contributions)             interest)

                                                                                    $                                              $                 

                                                                                                                                                        

                                                                                                                                                        

                                                                                    $                                              $                 

 

 

 

OTHER FUTURE INTERESTS AND SIMILAR ASSETS

 

                                                                                                                        Market

                                                                                                                        Value

                                                                                                                        (discounted

Description of Future Interest                                                                      amount)

                                                                                                                                                $                    

                                                                                                                                                           

                                                                                                                                               

 

                                                                                                                        $                   

 

2.  Describe nonforfeitable rights not included in the financial statements because they are contingent, e.g., annuity receivable contingent on retirement.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

 

 

 

 

 

 

 

OTHER ASSETS (AUTOS, PERSONAL PROPERTY, INTANGIBLE ASSETS, ETC.)

 

 

 

                                                How Was the Estimated                      Tax Basis                   Estimated

Description                             Current Value Determined? (original cost) Current Value

 

Automobiles:

                                                                                                            $                                  $                

                                                                                                                                                                   

                                                                                                                                                                                                                                              

                                                                                                            $                                  $                 

 

 

Furniture, appliances, art, antiques, etc.:

                                                                                                                                                                                       $                                            $                 

                                                                                                                                                                    

                                                                                                                                                                    

 

                                                                                                            $                                  $                 

 

Jewelry and furs:

                                                                                                                                                                                                                $                                            $                 

                                                                                                                                                                    

                                                                                                                                                                    

 

                                                                                                            $                                  $                 

 

Other Assets:

                                                                                                            $                                  $                 

                                                                                                                                                                     

                                                                                                                                                                    

 

                                                                                                            $                                  $                 

 

 

 

 

 

 

 

 

 

LIABILITIES

                                                                                                            Implicit

                                                            Maturity         Monthly          Stated                         Interest Rate

Payable to                  Collateral       Date                Payment         Interest Rate             (if different)                    Present Balance

                                                                                    $                                     %                                   %                     $                

                                                                                                                                                                                                           

                                                                                                                                                                                                            

                                                                                                                                                                                                                                                                                                                                                      

 

                                                                                                                                                                                    $                 

 

 

 

                        Description (major credit cards, utilities, property taxes, insurance, etc.)                                    Present Balance

                                                                                                                                                                                    $                  

                                                                                                                                                                                                        

                                                                                                                                                                                                        

                                                                                                                                                                                                        

                                                                                                                                                                                                        

                                                                                                                                                                                    $                  

 

 

 

Note following information for noncancellable commitments (e.g., fixed amounts of alimony for a definite future period and charitable pledges):                                                                                                                                                  

                                                                                                                                    Market Value  (Discounted

                                                Description                                                                                                     amount)

                                                                                                                               $                $               

                                                                                                                                                                   

                                                                                                                                                                                                                                                                                                                                        

 

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

 

INCOME TAXES

 

Estimated adjusted taxable income for the year                                              $                       

Estimated current year income taxes                                                               $                        

Withholdings, estimated taxes paid, overpayments credited

   Federal                                                                                                         (                        )

   State                                                                                                             (                        )

    Total withholdings                                                                                      (                        )

Current year income taxes payable

Unpaid taxes from completed tax years, if any

 

                                                                 TOTAL CURRENT YEAR INCOME TAXES PAYABLE   $                        

 

 

 

PERSONAL INCOME AND EXPENSES

 

Salary, wages, and bonuses                                                     $                         

Dividends and interest income                                                                          

Gains on sales of investments                                                              

Drawings from partnerships and proprietorships                                             

Consulting fees                                                                                                 

Others                                                                                                               

                                                                                                                          

                                                                                                                          

                                                                                                                          

 

 

 

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

Describe anticipated major purchases: _____________________________________________________________________________________________

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