Estate Planning Facts
Confidential Fact Finder for Wealth Planning Suite Provided by The Prudential Insurance
Company of America to Help Identify Insurance and Financial Product Needs
Personal Information
Full name: first ____________________ middle ______________ last ______________________________________
What name do you prefer to be called? _____________________________________ Sex: Male Female
Date of birth: ____________________ Citizenship: US Citizen Resident Alien Nonresident Alien
Are you married? Yes No Spouse’s sex: Male Female
Spouse’s full name: first ____________________ middle ______________ last ______________________________
Date of birth: ____________________ Citizenship: US Citizen Resident Alien Nonresident Alien
Principal Residence:
Address: ______________________________________________________________________________________
City: _______________________________________________ State: _____________________ Zip: _____________
Home phone: __________________________ Business phone: ___________________________ Extension: ________
E-mail: __________________________________________________________________________________________
How would you like to be contacted? Home phone Business phone E-mail
What is the best time to contact you? ____________________________________________________ am pm
Financial Professionals
Attorney: _________________________________________________ Phone: ____________________ ext. _______
CPA or Accountant: _________________________________________Phone: ____________________ ext. _______
Trust Officer: ______________________________________________ Phone: ____________________ ext. _______
Financial Planner: __________________________________________ Phone: ____________________ ext. _______
Broker: ___________________________________________________Phone: ____________________ ext. _______
Insurance Agent: ___________________________________________ Phone: ____________________ ext. _______
Other Professional: _________________________________________ Phone: ____________________ ext. _______
Date completed: _____________________________
ALL RIGHTS RESERVED. All information and forms contained herein are proprietary. Copyright The Prudential
Insurance Company of America. It is unlawful to copy, reproduce, or distribute the information contained in this document
without the express written authorization of The Prudential Insurance Company of America. Any questions regarding
these materials should be directed to: The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ
07102-3777.
Prudential, Prudential Financial, the Rock logo, and the Rock Prudential logo are registered service marks of The
Prudential Insurance Company of America and its affiliates.
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Children
1. Full name: ______________________________________________________ Date of birth: _____________________
Estimated educational cost per year: $ ___________________ starting in _____________ years for ________ years
2. Full name: ______________________________________________________ Date of birth: _____________________
Estimated educational cost per year: $ ___________________ starting in _____________ years for ________ years
3. Full name: ______________________________________________________ Date of birth: _____________________
Estimated educational cost per year: $ ___________________ starting in _____________ years for ________ years
4. Full name: ______________________________________________________ Date of birth: _____________________
Estimated educational cost per year: $ ___________________ starting in _____________ years for ________ years
Do you have any grandchildren? _______ Yes ________ No How many? _________________
Other Beneficiaries
Full name: ______________________________________________________ Date of birth: _____________________
Full name: ______________________________________________________ Date of birth: _____________________
Full name: ______________________________________________________ Date of birth: _____________________
Full name: ______________________________________________________ Date of birth: _____________________
Are there any special concerns, needs or arrangements to consider for your children, grandchildren, or others?
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Social Security
You: At what age would you expect to begin receiving Social Security? __________________
Your spouse: At what age would your spouse expect to begin receiving Social Security? __________________
Earned Income
Your current salary: $ ________________ Percent increase? ___________ Through age: _____________________
Your spouse’s current salary: $ ______________ Percent increase? __________ Through age: _________________
Additional Income
1. Source: ______________________________________________ Recipient: You Your spouse
Current amount: $ ________________ How many years should this income be assumed to continue? ______________
Assume annual increases? _______ Yes _______ No Average annual increase __________________ %
Will it continue to be paid at recipient’s death? _______ Yes _______ No If yes, how many years? _____________
2. Source: ______________________________________________ Recipient: You Your spouse
Current amount: $ ________________ How many years should this income be assumed to continue? ______________
Assume annual increases? _______ Yes _______ No Average annual increase __________________ %
Will it continue to be paid at recipient’s death? _______ Yes _______ No If yes, how many years? _____________
3. Source: ______________________________________________ Recipient: You Your spouse
Current amount: $ ________________ How many years should this income be assumed to continue? ______________
Assume annual increases? _______ Yes _______ No Average annual increase __________________ %
Will it continue to be paid at recipient’s death? _______ Yes _______ No If yes, how many years? _____________
Inheritances
1. Source: ______________________________________________ Recipient: You Your spouse
Likely amount: $ ________________ Smallest likely amount: $ _____________ Largest likely amount: $ ____________
Based on the life of: _____________________________ Age: ____________ Current health: _____________________
And, based on the life of: _________________________ Age: ____________ Current health: _____________________
2. Source: ______________________________________________ Recipient: You Your spouse
Likely amount: $ ________________ Smallest likely amount: $ _____________ Largest likely amount: $ ____________
Based on the life of: _____________________________ Age: ____________ Current health: _____________________
And, based on the life of: _________________________ Age: ____________ Current health: _____________________
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Checking, Savings & CDs
1. Type, name, or purpose of account: ____________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Value of this account: $ _____________ Estimated interest rate: ________ % Planned annual deposits: $ ___________
2. Type, name, or purpose of account: ____________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Value of this account: $ _____________ Estimated interest rate: ________ % Planned annual deposits: $ ___________
3. Type, name, or purpose of account: ____________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Value of this account: $ _____________ Estimated interest rate: ________ % Planned annual deposits: $ ___________
4. Type, name, or purpose of account: ____________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Value of this account: $ _____________ Estimated interest rate: ________ % Planned annual deposits: $ ___________
Bonds
1. Name of bond: ____________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Maturity (face) amount: $ ______________________ Matures in year: _____________________
Purchase price: $ ____________________________ Market value: $ ______________________
Tax exempt? _______ yes _______ no Coupon interest income: _______________
2. Name of bond: ____________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Maturity (face) amount: $ ______________________ Matures in year: _____________________
Purchase price: $ ____________________________ Market value: $ ______________________
Tax exempt? _______ yes _______ no Coupon interest income: _______________
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Mutual Funds
Do not include funds that are part of an IRA or employer sponsored retirement plan (401(k), TSA, etc.).
1. Name of fund or fund company: _______________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Current value: $ __________________ Cost basis: $ ________________ Annual deposits: $ _____________________
If not tax exempt:
Estimated annual dividend rate: _________________% Receive dividends as cash or Reinvest
Estimated annual capital gains rate: ______________% Receive capital gains or Reinvest
distributions as cash
If tax exempt:
Estimated annual distribution rate: _______________ % Receive distributions as cash or Reinvest
(1)
Appreciation rate for net asset value: ______________________%
2. Name of fund or fund company: _______________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Current value: $ __________________ Cost basis: $ ________________ Annual deposits: $ _____________________
If not tax exempt:
Estimated annual dividend rate: ________________ % Receive dividends as cash or Reinvest
Estimated annual capital gains rate: _____________ % Receive capital gains or Reinvest
distributions as cash
If tax exempt:
Estimated annual distribution rate: _______________ % Receive distributions as cash or Reinvest
(1)
Appreciation rate for net asset value: ______________________%
(1)
(Not including dividends or capital gains or tax-exempt distributions.)
Securities
Do not include stock in your business.
1. Name of stock: ____________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ______________________ What did it cost? $ _____________________
Dividend rate: ___________________ % Appreciation rate: _____________________ %
Dividends: Received as cash Dividend reinvestment program
2. Name of stock: ____________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ______________________ What did it cost? $ _____________________
Dividend rate: ___________________ % Appreciation rate: _____________________ %
Dividends: Received as cash Dividend reinvestment program
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Securities - continued
1. Name of stock: ____________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ______________________ What did it cost? $ _____________________
Dividend rate: ___________________ % Appreciation rate: _____________________ %
Dividends: Received as cash Dividend reinvestment program
2. Name of stock: ____________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ______________________ What did it cost? $ _____________________
Dividend rate: ___________________ % Appreciation rate: _____________________ %
Dividends: Received as cash Dividend reinvestment program
Real Estate
Principal Residence: Do you own your home? _______ Yes _______ No
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ____________________ Cost? $ __________________ Estimated appreciation rate: _______ %
Current mortgage balance: $ _______________ Interest rate for loan: ______% Monthly payment: $ _______________
Secondary Residence: Street name or location:___________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ____________________ Cost? $ __________________ Estimated appreciation rate: _______ %
Current mortgage balance: $ _______________ Interest rate for loan: ______% Monthly payment: $ _______________
Other Real Estate:
1. Street name or location:________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ____________________ Cost? $ __________________ Estimated appreciation rate: _______ %
Current mortgage balance: $ _______________ Interest rate for loan: ______% Monthly payment: $ _______________
2. Street name or location:_____________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ ____________________ Cost? $ __________________ Estimated appreciation rate: _______ %
Current mortgage balance: $ _______________ Interest rate for loan: ______% Monthly payment: $ _______________
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Business Assets
1. Business / Farm name or description: _______________________________________________________________
Address:_________________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Cost? $ __________________________ Fair market value of the share owned: $ _____________________________
Income other than salary from the business: $ ______________________
Estimated annual growth rate for the next 10 years: _________________%
What do you want to happen to the business/farm:
If you are disabled? ________________________________________________________________________
At your retirement? ________________________________________________________________________
At your death? ____________________________________________________________________________
2. Business / Farm name or description: _______________________________________________________________
Address:_________________________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Cost? $ __________________________ Fair market value of the share owned: $ _____________________________
Income other than salary from the business: $ ______________________
Estimated annual growth rate for the next 10 years: _________________%
What do you want to happen to the business/farm:
If you are disabled? ________________________________________________________________________
At your retirement? ________________________________________________________________________
At your death? ____________________________________________________________________________
Notes:
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Annuities
Do not include funds that are part of an IRA or employer sponsored retirement plan (401(k), TSA, etc.).
1. Description or name of annuity: _______________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Current Value: $ __________________ Cost basis: $ ________________ Annual deposits: $ _____________________
Estimated interest rate: ________________ %
At what age do you expect to start receiving income from this annuity? ______________
Preferred settlement option: Life only Life & 10-year certain Joint life
Joint & 50% survivor Other________________________________
2. Description or name of annuity: _______________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Current Value: $ __________________ Cost basis: $ ________________ Annual deposits: $ _____________________
Estimated interest rate: ________________ %
At what age do you expect to start receiving income from this annuity? ______________
Preferred settlement option: Life only Life & 10-year certain Joint life
Joint & 50% survivor Other________________________________
Deferred Compensation
Nonqualified deferred compensation, salary continuation, or executive bonus plans.
You:
How many years will
Expected annual payment: $ _________________ Age when payments start: __________ payments be made? _______
Will remaining payments continue after your death? _______ Yes ________ No
If yes,
Expected annual payment: $ ___________________ How many years will payments be made? ____________
To whom will payments be made? _____________________________________________________________
Your spouse:
How many years will
Expected annual payment: $ _________________ Age when payments start: __________ payments be made? _______
Will remaining payments continue after your death? _______ Yes ________ No
If yes,
Expected annual payment: $ ___________________ How many years will payments be made? ____________
To whom will payments be made? _____________________________________________________________
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Retirement Plans
Qualified retirement plans such as an IRA, 401(k), 403(b), profit sharing, defined benefit or other pension plans.
1. Description or name of account: ________________________________________ Participant: You Your spouse
Type of retirement plan: Deductible IRA Roth IRA Salary reduction [401(k), 403(b), etc.]
Profit sharing Defined Benefit Other _________________________
Value of this account: $ _____________________ Estimated interest rate: ___________________________ %
Your annual contribution: $ ___________________ How many years will you continue to contribute?_________
Employer’s contribution: $ ____________________ How many years will employer continue to contribute?_____
At what age do you expect to start receiving income from this plan? ______________
Beneficiary: ___________________________________________ Relationship: ________________________________
2. Description or name of account: ________________________________________ Participant: You Your spouse
Type of retirement plan: Deductible IRA Roth IRA Salary reduction [401(k), 403(b), etc.]
Profit sharing Defined Benefit Other _________________________
Value of this account: $ _____________________ Estimated interest rate: ___________________________ %
Your annual contribution: $ ___________________ How many years will you continue to contribute?_________
Employer’s contribution: $ ____________________ How many years will employer continue to contribute?_____
At what age do you expect to start receiving income from this plan? ______________
Beneficiary: ___________________________________________ Relationship: ________________________________
3. Description or name of account: ________________________________________ Participant: You Your spouse
Type of retirement plan: Deductible IRA Roth IRA Salary reduction [401(k), 403(b), etc.]
Profit sharing Defined Benefit Other _________________________
Value of this account: $ _____________________ Estimated interest rate: ___________________________ %
Your annual contribution: $ ___________________ How many years will you continue to contribute?_________
Employer’s contribution: $ ____________________ How many years will employer continue to contribute?_____
At what age do you expect to start receiving income from this plan? ______________
Beneficiary: ___________________________________________ Relationship: ________________________________
Notes: (Give details regarding any defined benefit plans, etc.):
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Personal Property & Other Assets
Personal property:
Personal property includes assets such as household furnishings, clothes, automobiles, boats, collectibles, jewelry, etc.
What is the value of:
Property owned jointly with spouse? $ ____________________
Your personal property? $ ____________________
Your spouse’s personal property? $ ____________________
Other assets:
1. Brief description or name: ___________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ _______________________ Cost: $ ________________________
Estimated income or earnings rate: ____________ % Estimated annual capital appreciation rate: ___________ %
(Not including income earnings)
Other comments about this item:
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2. Brief description or name: ___________________________________________________________________________
Owner: You Your spouse Joint with spouse Community property
Fair market value: $ _______________________ Cost: $ ________________________
Estimated income or earnings rate: ____________ % Estimated annual capital appreciation rate: ___________ %
(Not including income earnings)
Other comments about this item:
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Life Insurance Policies
1. Insured: ____________________________________ Company name or description: ___________________________
Owner: You Your spouse Joint with spouse
Community property Trust Other: _____________________
Beneficiary: ___________________________________________ Relationship: ________________________________
Face amount: $ ________________________________________ Cash value: $ _______________________________
Planned annual premium: $ ______________________________
2. Insured: ____________________________________ Company name or description: ___________________________
Owner: You Your spouse Joint with spouse
Community property Trust Other: _____________________
Beneficiary: ___________________________________________ Relationship: ________________________________
Face amount: $ ________________________________________ Cash value: $ _______________________________
Planned annual premium: $ ______________________________
3. Insured: ____________________________________ Company name or description: ___________________________
Owner: You Your spouse Joint with spouse
Community property Trust Other: _____________________
Beneficiary: ___________________________________________ Relationship: ________________________________
Face amount: $ ________________________________________ Cash value: $ _______________________________
Planned annual premium: $ ______________________________
4. Insured: ____________________________________ Company name or description: ___________________________
Owner: You Your spouse Joint with spouse
Community property Trust Other: _____________________
Beneficiary: ___________________________________________ Relationship: ________________________________
Face amount: $ ________________________________________ Cash value: $ _______________________________
Planned annual premium: $ ______________________________
Notes: (Include information for purpose, policy loans, termination of coverage, etc.):
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Disability Income Insurance
1. Policy or memo: ______________________________________ Insured: _____________________________________
Annual premium: $ _____________________ Monthly benefit: $ ___________________ or percent of salary: _______%
Elimination period: 30 Days 60 Days 90 Days 180 Days 365 Days
Benefit period: 2 Years 5 Years 10 Years To age____
COLA: ______% Simple Compound
2. Policy or memo: ______________________________________ Insured: _____________________________________
Annual premium: $ _____________________ Monthly benefit: $ ___________________ or percent of salary: _______%
Elimination period: 30 Days 60 Days 90 Days 180 Days 365 Days
Benefit period: 2 Years 5 Years 10 Years To age____
COLA: ______% Simple Compound
Long Term Care Insurance
1. Policy or memo: ______________________________________ Insured: _____________________________________
Annual premium: $ _____________________ Monthly benefit: $ ___________________ or percent of salary: _______%
Elimination period: 30 Days 60 Days 90 Days 180 Days Other _______
Benefit period: 2 Years 5 Years Lifetime Other _______
COLA: ______% Simple Compound
Other benefits: ____________________________________________________________________________________
2. Policy or memo: ______________________________________ Insured: _____________________________________
Annual premium: $ _____________________ Monthly benefit: $ ___________________ or percent of salary: _______%
Elimination period: 30 Days 60 Days 90 Days 180 Days Other _______
Benefit period: 2 Years 5 Years Lifetime Other _______
COLA: ______% Simple Compound
Other benefits: ____________________________________________________________________________________
Notes: __________________________________________________________________________________________
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Living Expenses
Include living expenses not accounted for elsewhere. Do not include expenses for investments, gifts, payments for a
debt or mortgage, or premium payments on existing life insurance policies.
Summarize as much as possible. These categories are only to help you summarize.
Percent Continuing
Monthly Annual Average after First
Expenses or Expenses Annual Increase Death (0 to 100%)
Household: $ __________ $ _______________ __________ % _________ %
Child care: $ __________ $ _______________ __________ % _________ %
Transportation total: $ __________ $ _______________ __________ % _________ %
Food: $ __________ $ _______________ __________ % _________ %
Clothing: $ __________ $ _______________ __________ % _________ %
Furnishings: $ __________ $ _______________ __________ % _________ %
Personal care & cash: $ __________ $ _______________ __________ % _________ %
Medical/Dental/Rx: $ __________ $ _______________ __________ % _________ %
Education: $ __________ $ _______________ __________ % _________ %
Entertainment: $ __________ $ _______________ __________ % _________ %
Vacation: $ __________ $ _______________ __________ % _________ %
Other: $ __________ $ _______________ __________ % _________ %
Other: $ __________ $ _______________ __________ % _________ %
Other: $ __________ $ _______________ __________ % _________ %
Total Expenses: $ __________ $ _______________
Notes:
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Personal Liabilities
Debts other than the mortgages already described, such as auto loans, credit card debts, etc.
1. Description of debt or liability: _________________________________________________________________________
Who is responsible for debt? You Your spouse Joint with spouse
Current amount of debt: $ __________________ Interest rate: ___________ % Monthly payment: $ ________________
2. Description of debt or liability: _________________________________________________________________________
Who is responsible for debt? You Your spouse Joint with spouse
Current amount of debt: $ __________________ Interest rate: ___________ % Monthly payment: $ ________________
3. Description of debt or liability: _________________________________________________________________________
Who is responsible for debt? You Your spouse Joint with spouse
Current amount of debt: $ __________________ Interest rate: ___________ % Monthly payment: $ ________________
4. Description of debt or liability: _________________________________________________________________________
Who is responsible for debt? You Your spouse Joint with spouse
Current amount of debt: $ __________________ Interest rate: ___________ % Monthly payment: $ ________________
5. Description of debt or liability: _________________________________________________________________________
Who is responsible for debt? You Your spouse Joint with spouse
Current amount of debt: $ __________________ Interest rate: ___________ % Monthly payment: $ ________________
Notes:
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Your Prior Planning
You:
Do you have a will? _______ Yes ________ No
If yes:
Charitable bequests: $ ________________ Bequests to persons other than surviving spouse: $ ____________
What does the will do with the remaining estate after the above are considered?
_____ Leaves everything to surviving spouse, otherwise to children
_____ Leaves everything to children, grandchildren or others
_____ Uses trusts to take advantage of the applicable credit amount (Often called Marital/Family or A-B trusts)
_____ Tries to use the applicable credit amount without a trust, remainder to spouse
_____ Leaves everything to someone other than surviving spouse
Notes: __________________________________________________________________________________________
Your Spouse:
Does your spouse have a will? _______ Yes ________ No
If yes:
Charitable bequests: $ ________________ Bequests to persons other than surviving spouse: $ ____________
What does the will do with the remaining estate after the above are considered?
_____ Leaves everything to surviving spouse, otherwise to children
_____ Leaves everything to children, grandchildren or others
_____ Uses trusts to take advantage of the applicable credit amount (Often called Marital/Family or A-B trusts)
_____ Tries to use the applicable credit amount without a trust, remainder to spouse
_____ Leaves everything to someone other than surviving spouse
Notes: __________________________________________________________________________________________
Prior Gifts
Have you made any gifts that required filing a gift tax return? _______ Yes _______ No
Total of these gifts: $ ______________________________ Total taxes paid on these gifts: $ _____________________
Has your spouse made any gifts that required filing a gift tax return? _______ Yes _______ No
Total of these gifts: $ ______________________________ Total taxes paid on these gifts: $ _____________________
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Comments
Please list any other items to be considered or explain any prior answers. Be sure to include special expenses, specific
needs, existing agreements, expected inheritances, existing trusts, and special bequests.
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Life insurance, long-term care insurance, and annuities are issued by The Prudential Insurance Company of America and
its affiliates. Securities are offered by Pruco Securities, LLC. Each is a Prudential Financial company located in Newark,
NJ, and is solely responsible for its own financial condition and contractual obligations. The availability of other products
varies by carrier and state.
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