Your Information: Name : Address Date of Birth : Sex : M F Earnings: Will : Y N Long-term care : Y N Spouse's Information Name : Spouse's Phone Number: Spouse's Date of Birth: Spouse's Sex : M F Spouse's Earnings: Long-term Care : Y N Life Insurance : Y N Insured's Information: List all Insureds' Names, the Insurance Company, the Face Amount, and the Insurance Type and Premium. Children: Name/DOB/Sex/College Need Long-Term Debts: List all Mortgages List any Additional Debts Liquid Assets Cash/Checking: Savings/Money Market Illiquid Assets Home: Investment Property Automobiles Other Retirement Values: ORP TRS-Years of Service TDA IRA/SEP 401K Def. Compensation Other Total Retirement Assets Personal & Family Priorities: (Please Rate) Short-Term Savings/Emergencies : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Funding Child's Education : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Assurance of Adequate Retirement Income : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Minimize Estate Taxes & Costs : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Provide for Nursing Home/ Health Care : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Lifetime or Testamentary Gifts to Children : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Income for Dependents : 1-Very Important 2-Important 3-Somewhat Important 4-Not As Important 5-Not Important Additional Notes/Comments Email: Phone Number :