Financial Planning Questionnaire

FINANCIAL PLANNING QUESTIONNAIRE

This form will help us gather the information necessary to perform an analysis of your current financial status and financial goals. Please remember: the accuracy and usefulness of any plans we do can be no greater than the answers given to these questions. If correct facts and figures are not available, it will be worthwhile to get them. If a question does not apply to you, do not answer it. If you need more space for answers, use a blank sheet of paper and separately identify each additional answer.

Please include with this questionnaire copies of wills, trusts, and estate plans, as well as a copy of your most recent tax return if we do not already have one. Do not send originals (or your only copy) of any documents.

It is the policy of George D. Kinder Financial Services to treat the information provided herein as absolutely CONFIDENTIAL. NOTHING will be released to any other party (including family members) without the expressed permission of the parties filling out this form.

CONFIDENTIAL 2

SECTION I - PERSONAL BACKGROUND

Name: ______Name: ______S.S. # : _____-______-______S.S. # : _____-______-______Birth Date : ____-_____-______Birth Date : ____-_____-______Occupation: ______Occupation: ______Work Phone: _____-_____-______Work Phone: _____-_____-______Address : ______Home Phone: ____-____-_____ City, State & Zip Code : ______

Name (Relation if appl.) Age Birth Date S.S. Number Health CHILDREN ______

YOUR EXTENDED FAMILY ______

OTHER’S EXTENDED FAMILY ______

Financial Planning Questionnaire George D. Kinder Financial Services, Inc. CONFIDENTIAL 3

SECTION II - BUDGET PLANNING

A. INCOME (Before Tax)

Yourself Spouse/Other Joint

Wages ______Net Self Employed ______Rental Income ______Other ______

B. ANNUAL EXPENSES Current Post-retirement Shelter Rent/Mortgage (includes taxes & insurance: Y/N) Property Taxes Home Insurance Utilities Repairs/Maintenance Furniture & Appliances Other Food Clothing Auto (including insurance & repair) Insurance Life Medical Disability Personal Care Education Entertainment Gifts Charity Child Care Vacations Savings (including tax deferred) Other ______

SECTION III - NET WORTH STATEMENT

Assets

Total Assets: Liabilities

Total Liabilities: NET WORTH:

SECTION IV - ASSETS AND LIABILITIES

A. TAXABLE

FIXED RETURN INVESTMENTS

TYPE OWNER INT MONTHLY VALUE MATURITY RATE PAYMENT MO/DAY/YR

TYPE: 1 - BANK SAVINGS; 2 - MONEY MARKET FUNDS; 3 - CDs; 4 - TAXABLE BONDS; 5 - MUNICIPAL BONDS; 6 - MORTGAGES, LOANS OR NOTES DUE TO YOU

SECURITIES: INCLUDING STOCKS, MUTUALS FUNDS, & WARRANTS

DESCRIPTION OWNER NO OF PURCHASE DATE OF CURRENT SHARES PR/ SHARE PURCHASE PR/ SHARE

SECTION IV - ASSETS AND LIABILITIES (CONT.)

B. TAX DEFERRED OR EXEMPT

FIXED RETURN INVESTMENTS

TYPE OWNER INT MONTHLY VALUE MATURITY RATE PAYMENT MO/DAY/YR

TYPE: 1 - BANK SAVINGS; 2 - MONEY MARKET FUNDS; 3 - CDs; 4 - TAXABLE BONDS; 5 - MUNICIPAL BONDS; 6 - MORTGAGES, LOANS OR NOTES DUE TO YOU

SECURITIES: INCLUDING STOCKS, MUTUALS FUNDS, & WARRANTS

DESCRIPTION OWNER NO OF PURCHASE DATE OF CURRENT SHARES PR/ SHARE PURCHASE PR/ SHARE

SECTION IV - ASSETS AND LIABILITIES (Cont.)

C. OTHER INVESTMENTS

LIST ALL OTHER INVESTMENTS, INCLUDING BUSINESSES, PARTNERSHIPS, COMPANY STOCK OPTIONS, JOINT VENTURES, AND DEBTS WHERE THE RECOVERY OF PRINCIPLE IS UNCERTAIN. IF YOU RECEIVE INCOME FROM THEM, PLEASE SHOW THE AMOUNT IN SECTION III A. IF YOU NEED REGULAR CASH PAYMENTS TO SUPPORT THESE INVESTMENTS, SHOW THAT IN THE ANNUAL EXPENSE PORTION OF SECTION III B

DESCRIPTION OWNER VALUE ANNUAL INC

D. REAL ESTATE LIST PERSONAL NON-INCOME PRODUCING (TYPE 1) AND INCOME PRODUCING (TYPE 2)

PROPERTY #1 PROPERTY #2 PROPERTY #3

DESCRIPTION LOCATION (STATE) OWNER TYPE PURCHASE DATE PURCHASE PRICE CURRENT VALUE ORIGINAL MORTGAGE MONTHLY PAYMENT INTEREST RATE MORTGAGE REMAINING YEARS REMAINING

E. CHILDREN’S INVESTMENTS

NAME OF CHILD

DESCRIPTION

PURPOSE

ANNUAL INCOME

F. FUTURE ASSETS LIST ALL OTHER ASSETS YOU ARE CERTAIN TO OR LIKELY TO RECEIVE IN THE FUTURE (I.E. TRUSTS AND INHERITANCES, PENSION PLANS AND SOCIAL SECURITY)

DESCRIPTION VALUE ANNUAL INCOME YR EXPECT

G. OUTSTANDING LIABILITIES (Mortgages to be listed in Section IIID) TYPE DEBTOR AMOUNT INT MONTHLY MONTHS OUTSTANDING RATE PAYMENT LEFT

TYPE: 1 – CHARGE ACCOUNT; 2 – CAR LOAN; 3 – STUDENT LOAN; 4 – HOME EQUITY LOAN; 5 – OTHER (PLEASE DESCRIBE)

SECTION V - INSURANCE

Please describe your present life, medical, disability, and liability insurance coverage. If you prefer, you may send a copy of each policy. PLEASE DO NOT SEND US THE ORIGINAL POLICIES. Financial Planning Questionnaire George D. Kinder Financial Services, Inc. CONFIDENTIAL 9

A B LIFE INSURANCE Owner insured Beneficiary Face Amount Annual Premium Current Year Dividend Cash Value

DISABILITY INSURANCE Owner Insured Monthly Benefit Annual Premium Renewability Benefit Period Elimination Period

MEDICAL INSURANCE Owner Insured Annual Premiums Benefit Limit Deductible

PROPERTY INSURANCE HOMEOWNERS AUTOMOBILE Type Annual Premium Deductible Liability Coverage Dwelling Coverage Personal Property Coverage Damage to own Auto

EXCESS LIABILITY Annual premium Coverage

SECTION VI - YOUR FINANCIAL GOALS

A. EDUCATION Will your child(ren) attend: Private school?: ______Est. annual cost?: ______

College?: ______Est. annual cost?: ______

B. LIFE PROTECTION Assuming the mortgage is paid, what would your spouse’s after-tax income requirements be in the case of your premature death?: ______What after-tax monthly income per child would be required until he/she leaves home or begins College?: ______

C. DISABILITY PROTECTION What income would you require if you were to become permanently and totally disabled? ______

D. RETIREMENT At what age do you plan to retire: ______Assuming your spouse is your only dependent, and your mortgage is paid, what after-tax retirement income will you require (in today’s dollars): ______Are you eligible for Social Security: ______If your company has a fixed benefit retirement program, what do you estimate your payments will be: ______Do you own any other tax-sheltered retirement funds: (IRA, KEOGH, Deferred Compensation, TSA, Profit Sharing, 401K, etc.):

DESCRIPTION OWNER VALUE CONTRIBUTION

Please provide us with a copy of your latest statement and a copy of your investment choices within company plans.

E. OTHER GOALS

Please list other financial goals you may have in the space provided. Examples include investment in business opportunities, recreational items (boat, vacation, etc.), trust funds for children, or any other currently known future need for substantial cash.

DESCRIPTION AMOUNT NEEDED YEAR NEEDED

F. INVESTMENT GOALS If the following analysis is to reflect your personal goals, we must completely understand your personal investment philosophy. Therefore, please indicate the importance to you of each of the following investment attributes:

Level of Importance

Investment Objective Most Very Some Little None Long Term Aggressive Growth; no concern over account fluctuation High Current Income Little Fluctuation in Account Value Preservation of Capital

SECTION VII- GENERAL QUESTIONS

These questions are designed to help us understand your overall financial condition and concerns. If you have additional comments or questions, please feel free to express them. Also, we would like to reiterate here that we hold the material presented in this questionnaire in the highest confidence, and will not divulge ANY of it to anyone without your expressed permission.

1. Are you currently living on your wages or do you also depend on investment income?

______

2. Are you currently living on your income or spending more than is coming in?

______

3. To what extent are your family members and others who depend on you for support capable

of dealing with financial affairs? ______

______

4. Do you have concerns about health - either yours, your family or your parents?

______

5. What are your career goals and time frame? ______

______

6. Describe something of your history and luck as an investor. For example, do you try to time your investments with the business or stock market cycles? Do you use leverage? Do you follow a policy of diversification? What are your general investment goals?

______

7. If you have an investment advisor, are you satisfied with his/her performance? If not, why not?

______

8. When was the last time you had your will reviewed? ______

9. What questions or concerns would you like us to concentrate on in developing a financial plan for

you? ______

______

10. Please make any additional comments or ask any questions you may have

______

Signature(s) of party or parties filling out this form:

______Date: ______

Financial Planning Questionnaire George D. Kinder Financial Services, Inc. CONFIDENTIAL