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					                                   Personal Financial

                                            Information

                                           Organizer for

        Client Name(s):            ________________________________

                                   ________________________________

        Planner:                   ________________________________

        Date Completed: ________________________________




Securities and advisory services offered through SII Investments, Inc. (SII), member FINRA/SIPC and a registered
                     Investment Advisor. SII and First Capital Management are separate companies.




                                                  Confidential
                                Table of Data Forms

CATEGORY                         ___________      ______________   ______   PAGE

General           Identification…………………………………………..…………………………………..4
                  Tax and Technical Data
                  Business Information
Liquid Assets     Cash/Checking Account………………..……………………………………………….…5
                  Savings Account
                  Money Market Funds
Personal Assets   Residence……………………………………………………………………………….…6
                  Vehicle
                  Personal Property
                  Other Personal Assets
Liabilities       Home Mortgage………………………………………………………………………..….6
                  Amortized Personal Debt
                  Other Personal Debt
Assets            Annuities……………………………………………………………………………….….7
                  Stocks
                  Mutual Funds
Retirement        IRAs……………………………………………………………………………………….8
                  Keogh Plan
                  Company Retirement Plan
                  Other Retirement Plan
Benefit Plans     Deferred Comp………………………………………………………………………….…9
                  Profit Sharing
                  Stock Options
Insurance          Life Insurance ………………………………………………………………………….10
                  Disability Insurance
                  Home, Medical & Property
Income            Earned Income…………………………………………………………………………..11
                  Lump Sum Distribution
                  Interest and Dividends
                  Other Taxable Income
                  Capital Gains & Losses
                  Carryovers & Adjustments
Cash Flows         Living Expenses/Cash Outflows……………………………………………………...…12
Estate Planning    Wills/Trust Information………………….…………… ..……………………………...13
Goals              Summarize Financial Goals and Objectives……………………………………………..14
Advisors           List of Advisors doing business with……………………………………………………15




                                         2
Documents We Need From You_____________________________________________________________

You may be able to save yourself time in completing this financial information organizer by providing
documents (loan statements, mutual fund statements, insurance policies, etc.) rather than completing the
appropriate sections. Additionally, these documents may provide additional detailed information that
could be useful in preparing our recommendations. We will copy and return all original documents to
facilitate prompt completion of your financial information organizer.


              Tax Returns and Information
                    Past 2 year’s income tax return(s)
                    Gift tax returns filed since 1976
                    Recent pay stub

              Brokerage Account Statements
                     Statements of transactions since January this year
                     Mutual Fund Statements

              Mortgage Statements
                    You will need initial terms of any mortgages and information regarding any prepayments

              Other Loan Statements
                     You will need to know the initial terms of the loans and information regarding any
                     prepayments

              Limited Partnership Statements
                     Prospectus, latest reports, K-1s etc.

              Financial Records and tax returns for Business Interests

              Retirement Plan Information

              IRA and/or Keogh Statements

              Pension, 401(k) and Profit Sharing Plan Statements
                     Benefits Manual

              Insurance Policies
                     Company group policy
                     Individual policies

              Employee Benefits
                    Company pension plan
                    Deferred compensation plan
                    Company stock option plan

              Social Security Estimate of Benefits Statement

              Copies of current Wills


                                                       3
                                    PERSONAL AND FAMILY INFORMATION

This section is for recording general information about yourself and, if applicable, about your spouse and
dependents. If you are married, please fill in the applicable details about yourself and, if the information is
different than yours, about your spouse.

Personal Information
Item                                                        Yourself                            Your Spouse
Last Name(s)
First Name, MI
Preferred Name
Street Address
City, State, Zip
Home& Mobile Phone
Work Number
Fax Number
Email Address
Social Security No.
Date of Birth and Place of Birth
Drivers License #

Tax & Technical Data
Tax Filing Status
(Enter S-Single; J-Joint; H-Head of Hsehld   M-filing Separately; Q-Qualified Widow )
Total Dependents you claim
State(s) in which you file taxes
Age at which work began                      Client:           Spouse:
Retirement Age desired                       Client:           Spouse:

Business Information
Item                                                        Yourself                            Your Spouse
Occupation
Employer
Length of Employment
Job Title
Street Address
City, State, Zip
Provides Pension Plan                           Yes____       No_____                     Yes______     No______
       If yes see ________
Employment Plans



Children and Other Dependents
        Name              Relation                           Birth date           Year to Graduate     Anticipate Post
                                                                                        H.S.          H.S. Educ. Y or N



                                                                4
                                               CASH ON HAND

Please provide copies of current bank account statements of any and all liquid assets that generate interest
income – such as Money Market funds, Corporate Bonds, US Bonds and Treasury Bills.

Cash and Equivalents (Checking, Savings, Money Market Funds)
Name of Account                            Owner*            Balance                         Interest Rate
                                            Circle                                             Per year
              Cash on Hand                  8-1-2-6     $                                                 %
1. Checking
1.
2.
3.
2. Savings/Now Accounts
1.
2.
3.
4.
3. Certificates of Deposit
1.
2.
3.
4.
5.
6.
7.
8.
4. Money Market Funds
1.
2.
3.
4.

Treasury Bills, Us Bonds, Corporate Bonds, Municipal Bonds
Name of Bond/T-Bill        Owner*        Total        Current              Interest        Risk           Date
                            Circle        Cost         Value                Rate         Factor**        Mature
                                                                           Per year
                              8-1-2-6      $                $                     %      1-2-3-4-5
1.
2.
3.
4.
5.

*Owner: 8 – Individual Client, 1 – Individual Spouse, 2 – Joint, 6 - Trust
**Risk Factor: 1 – Safe, 2 – Low Risk, 3 – Medium Risk, 4 – High Risk, 5 – Extremely Risky.




                                                        5
                                             PERSONAL ASSETS

Primary Residence                                           Second/Vacation House or Property
Description:    _______________________________             Description: _____________________________
Current Value: $_________________                           Current Value: $_________________
Real Estate Tax $_________________                          Real Estate Tax: $________________
Insurance Prem $_________________                           Insurance Prem $_________________
Amount Insured for $______________                          Amount Insured for $______________
*Owner__________                                            *Owner__________

Mortgage:                                                   Mortgage:
Orig. Amount $_______________                               Orig. Amount $_______________
Borrowed in ____/____ (mo/yr)                               Borrowed in ____/____ (mo/yr)
Over _______ years at __________% interest                  Over _______ years at __________% interest
With a balloon payment in _____/_____ (mo/yr)               With a balloon payment in ____/____ (mo/yr)

Second Mortgage (if any):                                   Third Mortgage (if any):
Orig. Amount $_______________                               Orig. Amount $______________
Borrowed in ____/____ (mo/yr)                               Borrowed in ____/____ (mo/yr)
Over _______ years at __________% interest                  Over _______ years at _________% interest
With a balloon payment in _____/_____ (mo/yr)               With a balloon payment in ____/____ (mo/yr)

*Owner: 8 – Individual Client, 1 – Individual Spouse, 2 – Joint, 6 - Trust

For Non-Real Estate personal assets - data pertinent only if a loan/lease is attached to the asset.
Vehicle:                                                    Vehicle:
Make & Year: __________________________                     Make & Year: _________________________
Current Value: $_____________________                       Current Value: $_____________________
Insurance Prem: $_________________                          Insurance Prem: $_________________
*Owner _______________                                      *Owner_______________

Loan/Financing                                              Loan/Financing
Orig. Amount $_______________                               Orig. Amount $______________
Borrowed in ____/____ (mo/yr)                               Borrowed in ____/____ (mo/yr)
Over _______ years at __________% interest                  Over _______ years at _________% interest
With a balloon payment in _____/_____ (mo/yr)               With a balloon payment in ____/____ (mo/yr)
Other Personal Asset (Boat, Motorcycle, etc.)               Personal Property:
Description:    _______________________________             Description: _____________________________
Insurance Prem: $_________________                          Insurance Prem: $________________
Current Value: $_________________                           Current Value: $_________________
*Owner _______________                                      *Owner_______________

Loan/Financing                                              Loan/Financing
Orig. Amount $_______________                               Orig. Amount $______________
Borrowed in ____/____ (mo/yr)                               Borrowed in ____/____ (mo/yr)
Over _______ years at __________% interest                  Over _______ years at _________% interest
With a balloon payment in _____/_____ (mo/yr)               With a balloon payment in ____/____ (mo/yr)

Credit Card Balances:                                       Other Amortized Debt:
Orig. Amount $_______________                               Orig. Amount $______________
Borrowed in ____/____ (mo/yr)                               Borrowed in ____/____ (mo/yr)
Over _______ years at __________% interest                  Over _______ years at _________% interest
With a balloon payment in _____/_____ (mo/yr)               With a balloon payment in ____/____ (mo/yr)


                                                        6
                                        NON-QUALIFIED ASSETS

This section is to provide information on all Stocks, Mutual Funds and Annuities currently held by you or your
spouse. You may choose to send us copies of statements instead of completing this section.

          Name of                Owner*        Amount         Orig            Current       Risk       Div’s
          Security                Circle         Of           Cost             Value      Factor**    Cash or
          Or Fund                              Shares       Per Share           Per                   Reinvest
                                               Owned                           Share
STOCKS                            8-1-2-6                   $             $               1-2-3-4-5    C or R
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
MUTUAL FUNDS
1.
2.
3.
4.
5.
6.
7.


Tax Deferred Fixed or Variable Annuities
Name of Annuity            Owner*                 Original Amount         Current Value       Current Interest
                            Circle                    Invested                                     Rate

                              8-1-2-6         $                       $                                      %
1.
2.
3.
4.
5.
6.
7.

*Owner: 8 – Individual Client, 1 – Individual Spouse, 2 – Joint, 6 - Trust
**Risk Factor: 1 – Safe, 2 – Low Risk, 3 – Medium Risk, 4 – High Risk, 5 – Extremely Risky.



                                                       7
                                            RETIREMENT PLANS

Please answer the following questions about your future retirement goals.
                                                                            Client   Spouse/Second Person
   1. At what age do you plan to retire?
   2. Do you plan on living in your current residence, once retired?
       Do you have or plan to have a second/vacation home?
       What are the expected costs of the second/vacation home?
   3. What is your date of employment with your current employer?
   4. Does your employer provide a pension plan?
       At retirement, what are the estimated annual benefits?
       Are these estimates present value or future value?
   5. Are you currently contributing to a retirement plan
       (e.g., 401(k), SEP, TSA, etc.)?
       What percentage of your income do you contribute?
       What percent is matched by your employer?
   6. Is profit sharing offered by your employer?
       If so, how much or what percentage?
   7. Do you save for retirement in any other investments,
       other than IRA’s and qualified plans?
       How much?
   8. While retired, do you plan on working to enhance
       your income?
       What is the amount you will earn?
       For how long after retired?
   9. In retirement, do you assume you will receive
       Social Security benefits?
   10. Does your employer provide any post-retirement medical
       benefits prior to age 65?
   11. Is a pre-Social Security bridge (a larger payment given
       years prior to the effective benefit date of Social Security,
       age 62/65) provided by your employer?
       If so, how much?




                                                         8
                                   RETIREMENT PLANS CONTINUED
Please supply us with copies of your most current statements.
IRA
Name of Account               Owner*         Contribution       Balance            Est Rate     Risk Factor**
                                Circle         Per Year                           Of Return
IRA’S                          8-1-2-6                        $                           %         1-2-3-4-5
1.
2.
3.
4.
ROTH IRA’S
1.
2.
3.
4.
EDUCATIONAL
IRA’S
1.
2.
3.
4.
5.
6.

Company Retirement Plans and Employee Benefits Plans
Name of Account      Owner*     Employee        Employer                     Balance     Interest       Risk
(SEP; 401k; Pension;  Circle   Contribution Contribution                                  Rate        Factor**
Deferred Comp; etc.)            Per Year         Per Year                                Per year

                          8-1-2-6    $                $                  $                      %     1-2-3-4-5
1.
2.
3.
4.
5.
6.
7.
8.

Are you or your spouse eligible for any Defined Benefit Retirement Plan? If so, please estimate benefit taken.

*Owner: 8 – Individual Client, 1 – Individual Spouse, 2 – Joint, 6 - Trust

Please provide any additional information that may further assist in explaining your current Retirement Plans
and Benefits:
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________


                                                          9
                                                 INSURANCE

Please provide the most recent policy statement and/or premium notice for each policy.

Life Insurance
    Each Policy             Policy 1               Policy 2               Policy 3               Policy 4
Insurance Company

Policy Number

Policy Type*

Name of Insured

Name of Owner

Name of
Beneficiary
Face Value

Cash Surrender
Value
Amount of any
Outstanding loans
Interest Rate

Annual Premium

*Type Code: W=Whole Life; T=Term; G=Group; U=Universal; X=None of these

Disability Insurance                                       Medical Insurance
Description             Yourself        Spouse             Description               Yourself      Spouse
Insurance Company                                          Insurance Company
Group or Personal                                          Group or Personal
Annual Benefit                                             Annual Premium
Annual Premium                                             Deductible Amount
Waiting Period                                             Coverage Amt. or %
Max. Benefit Period                                        Maternity Benefits

Property Insurance
    Each Policy            Property 1             Property 2            Property 3              Property 4
Item Insured

Insurance Company

Face Amount

Deductible Amount


                                                      10
                                     INCOME AND CASH RECEIVED

Please attach copies of current payroll check stubs and include a copy of previous year tax return and W-2’s.

Item                           Yourself/Joint          Est. Increase       Your Spouse           Est. Increase
Wages & Salaries           $                                      %    $                                         %
Bonus                      $                                      %    $                                         %
Taxable Benefits           $                                      %    $                                         %
Consulting Income          $                                      %    $                                         %
Deferred Compensation      $                                      %    $                                         %
Other Self Employed        $                                      %    $                                         %
Income
Child Support or           $                                       % $                                           %
Alimony
Social Security            $                                       %   $                                         %
Pension                    $                                       %   $                                         %
Gifts & Inheritance        $                                       %   $                                         %
Rental Income              $                                       %   $                                         %
Royalties                  $                                       %   $                                         %
Estate & Trust Income      $                                       %   $                                         %
Other Tax-Free             $                                       %   $                                         %


                                          INVESTMENT PROFILE


Your response on the following table will help us find the investment diversification that suits your desired
return and your risk objectives. Please circle the most suitable number in each category.


Investment Objectives                                      ________________Importance________________
                                                          Most     Very     Some      Little    None
High Long-Term Total Return                                 5        4        3          2       1
Capital Appreciation                                        5        4        3          2       1
Capital Preservation                                        5        4        3          2       1
Tax Advantages                                              5        4        3          2       1
High Current Income                                         5        4        3          2       1
Low Total Return Fluctuation                                5        4        3          2       1
Low Single Period Loss Probability                          5        4        3          2       1
High Degree of Liquidity                                    5        4        3          2       1


What do you expect the average inflation rate to be over the next 3 years? __________%
Do you expect it to change after 3 years?     ____ Yes ____ No. If yes, to what _____%
What is your expected rate of return from investing discretionary cash? _____%
Do you expect the top tax rate in 10 years to remain at the current level? ____ Yes _____ No.
If no then what top tax rate do you anticipate for Federal Income Tax? ________%
                                                For State Income Tax? ________%


                                                        11
                                   LIVING EXPENSES


      Expense Item              Amount        Per Year/Month    Month and Year
                                              Indicate Y or M   Payments to discontinue
          Household         $
Rent or Mortgage            $
Utilities                   $
Heat                        $
Property Tax                $
Water                       $
Garden Supplies             $
Telephone (Home & Cell)     $
Property Insurance          $
Garbage Collection          $
Condominium Fees            $
Household Maint./Cleaning   $
       Transportation
Car Payment                 $
Second Car Payment          $
Gasoline                    $
Auto Maint./Cleaning        $
Auto License Fees           $
Auto Insurance              $
Bus/Taxi/Tolls              $
Parking                     $
            Meals
Groceries                   $
Delivered Goods             $
Snacks                      $
Work Lunches                $
School Lunches              $
Meals Out                   $
       Entertainment        $
Vacations                   $
Movies/Plays
Spectator Sports            $
Sports Equipment            $
Cable/Movie Rental          $
           Savings          $
Credit Union                $
Bank
Education Fund              $
Company Saving              $
IRA                         $
                            $
                            $



                                         12
                                  LIVING EXPENSES CONTINUED


        Expense Item                 Amount          Per Year/Month    Month and Year
                                                     Indicate Y or M   Payments to discontinue
            Medical
Medications                   $
Insurance                     $
Doctor                        $
Dentist                       $
Health Club/Exercise Class    $
          Educational
Lessons                       $
Tuition                       $
Books/Papers/Magazines        $
           Charitable
Church/Synagogue              $
Political                     $
Charitable                    $
Other                         $
        Misc. Expenses        $
Legal                         $
Child Care                    $
Allowances                    $
Gifts                         $
Pet Food                      $
Pet Medical                   $
Barber/Beauty                 $
Toiletries                    $
Tobacco                       $
Alcohol                       $
Clothing Purchases            $
Clothing Maint./Cleaning      $
Other                         $


                             PLANNED MAJOR FINANCIAL EXPENSES


           Description                   Date of Event                 Estimated Cost
1.
2.
3.
4.
5.




                                              13
                                            ESTATE PLANNING

The information you provide in this section will be used to prepare your estate planning profile. We will
analyze this profile in the light of your objectives for maximum conservation of your family assets.

___________________Yourself_______________                  __________________Spouse_________________

Have a Will:          __________                            Have a Will:          __________

Type of Will*           __________                          Type of Will*           __________
When was it last reviewed: ____________                     When was it last reviewed: ____________
Have you established any trusts? ____Yes____No              Have you established any trusts? ____Yes____No
If yes please describe:                                     If yes please describe:
__________________________________________                  __________________________________________
__________________________________________                  __________________________________________
__________________________________________                  __________________________________________

*Type of Will: 1 = Simple Wills; 2 = Specific               *Type of Will: 1 = Simple Wills; 2 = Specific
Bequest Will; 3 = Maximizing available Unified              Bequest Will; 3 = Maximizing available Unified
Tax Credit; 4 = A-B Trust Will executed before              Tax Credit; 4 = A-B Trust Will executed before
1982.                                                       1982.

Prior Gifts                                                 Prior Gifts
Please indicate below any gifts made since 1976             Please indicate below any gifts made since 1976
that exceeded the annual exclusion limit and on             that exceeded the annual exclusion limit and on
which you had to pay gift tax.                              which you had to pay gift tax.

  Date of Gift     Gift Amount          Gift Tax              Date of Gift     Gift Amount          Gift Tax
1.                $                 $                       1.                $                 $
2.                $                 $                       2.                $                 $
3.                $                 $                       3.                $                 $

Current & Planned Gifts                                     Current & Planned Gifts
List below any gifts you plan to make in future.            List below any gifts you plan to make in future.

  Date of Gift     To Whom**         Gift Amount              Date of Gift     To Whom**         Gift Amount
1.                                  $                       1.                                  $
2.                                  $                       2.                                  $
3.                                  $                       3.                                  $


     Item         To Whom**           Value                      Item          To Whom**             Value
  Bequeathed                                                  Bequeathed
1.                                $                         1.                                  $
2.                                $                         2.                                  $
3.                                $                         3.                                  $
4.                                $                         4.                                  $
** Valid Response: Spouse, Child and Other

                                                       14
                                   ESTATE PLANNING QUESTIONAIRE

In the event of your spouse’s death would you:
                                                            Client   Spouse/Second Person

Work outside the home?                                      Yes/No        Yes/No
       When would you start?
       What would be your annual income?
Retire at the same age?                                     Yes/No        Yes/No
       If not, what age?
Maintain your education goals?                              Yes/No        Yes/No
       If not, what percent would you maintain?
Sustain your accumulation goals?                            Yes/No         Yes/No
       If not, what percent would you sustain?
Keep the same residence?                                    Yes/No         Yes/No
       If so, would you like the mortgage paid off?         Yes/No         Yes/No
Buy a new home?                                             Yes/No         Yes/No
       If so, would you like it paid for?                   Yes/No         Yes/No




In the event of your spouse’s disability, would you:
Work outside the home?                                      Yes/No        Yes/No
       How long after would you start?
       What would be your annual income?
Maintain your education objectives?                         Yes/No         Yes/No
       If not, what percent would you maintain?
Sustain your accumulation goals?                            Yes/No         Yes/No
       If not, what percent would you sustain?




                                                       15
                                  FINANCIAL GOALS AND OBECTIVES


Please describe your financial goals and objectives in any of the following areas that apply to your situation:

Current and projected living standard, including major items desired, e.g. house
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Children upbringing and education
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Investments
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Retirement
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Insurance needs in the event of death and disability
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Estate conservation, including specific bequests and charity concerns
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Please rate each of the following financial objectives to reflect your level of interest:
(circle your choice)
        Financial Objectives                                 ________________Importance________________
                                                           Most         Very        Some  Little None
Enhance Lifestyle                                             5           4           3     2     1
Purchase Major Asset                                          5           4           3     2     1
Accumulate Wealth Faster                                      5           4           3     2     1
Hedge Against Inflation                                       5           4           3     2     1
Reduce Taxes                                                  5           4           3     2     1
Family Protection Against Death & Disability                  5           4           3     2     1
Provide for Comfortable Retirement                            5           4           3     2     1
Estate Conservation                                           5           4           3     2     1
Children’s Education                                          5           4           3     2     1
Other                                                         5           4           3     2     1

                                                        16
                                          FINANCIAL ADVISORS

Please provide us with the names of your other financial advisors. List the name of the advisor, their firm,
address and telephone numbers.

Accountant
               Name_____________________________________ Telephone__________________________
               Company______________________________________________________________________
               Address_______________________________________________________________________


Attorney
               Name_____________________________________ Telephone__________________________
               Company______________________________________________________________________
               Address_______________________________________________________________________


Stockbroker
               Name_____________________________________ Telephone__________________________
               Company______________________________________________________________________
               Address_______________________________________________________________________


Banking Contact
             Name_____________________________________ Telephone__________________________
             Company______________________________________________________________________
             Address_______________________________________________________________________


Life Insurance Agent
               Name_____________________________________ Telephone__________________________
               Company______________________________________________________________________
               Address_______________________________________________________________________


Property/Casualty Insurance Agent
              Name_____________________________________ Telephone__________________________
              Company______________________________________________________________________
              Address_______________________________________________________________________


Investment Advisor
             Name_____________________________________ Telephone__________________________
             Company______________________________________________________________________
             Address_______________________________________________________________________

Other Advisors
              Name_____________________________________ Telephone__________________________
              Company______________________________________________________________________
              Address_______________________________________________________________________

                                                       17
                                        5886 Blackshire Path
                                   Inver Grove Heights, MN 55076
                                           (651) 731-3100
                                         Fax (651) 731-8527
Securities and advisory services offered through SII Investments, Inc. (SII), member FINRA/SIPC and a registered
                Investment Advisor. SII and First Capital Management are separate companies.




                                                          18
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