Physician s Personal Finance Organizer Please use this organizer to

Physician’s Personal Finance Organizer • Please use this organizer to provide information we need to serve you. Information you provide here is subject to our Privacy Notice. • If you’ve been asked to send this organizer back to us, please fax it to 866-249-1693 or mail it to: Utley Financial Planning Inc. 399 East 10th Avenue Suite 103 Eugene OR 97401. • If you have questions, call us at 541-463-0899 (888-465-0899 throughout Oregon). • PLEASE PRINT CLEARLY. Tell Us About Yourself Client1 (C1) Full legal name Name you go by Email address Mailing address Home address (if different) Home phone Office phone: main Office phone: direct Cell phone Pager Birth date Social Security # Have you ever or are you now engaged in litigation, arbitration, or mediation with or against a professional (e.g. a doctor, dentist, attorney, accountant, tax preparer, insurance agent, No Yes financial planner, stockbroker, investment advisor, etc.)? Client2 (C2) Organize Your Family • Information you provide about your family helps us do college planning, estate planning and gift planning. Your Children Child1 Name Birth date SS # Special needs/issues If any of your children are under the age of 21 and have substantial assets OR if someone other than you is paying for a substantial portion of their college education (a grandparent, for example), give specific details below, including dollar amounts if possible. Not applicable. Child2 Child3 Child4 Child5 Your Parents Client1 Mother’s name Mother’s age Mother’s health Mother’s occupation Mother’s special needs/issues Father’s name Father’s age Father’s health Father’s occupation Father’s special issues If you expect to receive an inheritance in five years or less, please give details here. Not applicable Not applicable good ( deceased age ___) fair poor good ( deceased age ___) fair poor good ( deceased age ___) fair poor good ( deceased age ___) fair poor Client2 Physician’s Personal Finance Organizer Page 2 of 17 Money & Marriage As a married couple, how often do you fight about money? never occasionally too often Who is your family’s in-house money handler? (Hint: This person usually balances the checkbook, pays the bills, handles insurance and makes investments.) Client1 Client2 Shared equally List all the states/countries in which you resided during the course of your current marriage: I’m not married. Attach These Documents (if applicable) Prenuptial agreement Divorce decree Property settlement Physician’s Personal Finance Organizer Page 3 of 17 Organize Your Background • Information you provide about your background helps us begin to know you as a person. Beginnings Client1 City & state of birth Place where you grew up Citizenship US US Client2 Education, Training & Profession • Please give the name, city and state of schools/trainings you attended. • If you have a curriculum vitae (CV), attach it and skip this section. Client1 ( Undergraduate Graduate Medical school Internship Residency Fellowship Board Cerification1 Board Cerification2 Employer/practice group Specialization Subspecialty see attached CV) Client2 ( see attached CV) Physician’s Personal Finance Organizer Page 4 of 17 Organize Your Wealth Management Team • When you provide detailed contact information about your financial vendors/specialists, it helps us to work seamlessly to serve you. • In the column below marked “Score”, please rate each of the specialists/vendors on a scale from 1 to 3 (3=good, 2=fair, 1=poor). Name & Firm Banker/loan officer Insurance agent: auto Insurance agent: homeowner’s Insurance agent: disability Insurance agent: life Insurance agent: health Legal specialist/attorney Mortgage broker/lender Real estate agent Stockbroker1 Stockbroker2 Tax specialist/ accountant City, State Score Physician’s Personal Finance Organizer Page 5 of 17 Organizer Your Medical Practice Management Team • When you provide contact information about your practice, we can help you get the most out of your employee benefits package. Client1 ( Group manager/ administrator Name: Phone: Email: Hr/payroll manager Name: Phone: Email: Clinical/Surgical scheduler Name: Phone: Email: When we need to schedule a meeting or teleconference with you, who should we contact? When we need to find you during business hours, who is most likely to know your whereabouts? Not a physician) Client2 ( Name: Phone: Email: Name: Phone: Email: Name: Phone: Email: Not a physician) Client1 Client2 Group Manager (above) Scheduler (above) other: Client2 Group Manager (above) Scheduler (above) Other: Client1 Client2 Group Manager (above) Scheduler (above) other: Client1 Group Manager (above) Scheduler (above) Other: Physician’s Personal Finance Organizer Page 6 of 17 Organize The Issues In Your Financial Life • Please place a checkmark by the statement describes your situation Client1 Client2 I need help with: Developing or revising my investment strategy Saving and investing for a comfortable retirement Building funds for education Providing for the care of loved ones Making gifts to relatives and/or charity Planning my estate to minimize costs/hassle to family Providing for my family in the event of death or disability Making a career change Saving for a major purchase or sabbatical Budgeting or managing my expenses better Improving communications about money in my family My credit history is: Good: I’ve paid my bills on time/ never declared bankruptcy Fair: I’ve had a few bills past due Poor: I have delinquencies, repossessions or a bankruptcy In the near future, I expect to: Retire Change jobs Get married or get divorced Have/adopt a child Experience the death of a loved one Buy a house or move Send my child to college Buy/sell a business Receive an inheritance Physician’s Personal Finance Organizer Page 7 of 17 Organize Your Assets • Attach complete documentation (statements, etc.) showing (a) the owner’s name, (b) the amount and value of the asset and (c) values for positions (securities) held in accounts, where applicable. • If you provide originals, they will be returned to you promptly. Attach These Documents (if applicable) RETIREMENT ACCOUNTS SEP-IRA, SIMPLE-IRA, Keogh, “solo 401k” account statements Defined-benefit pension & Public Employees Retirement System account statements 457/deferred compensation plan statements 401k, Roth 401k, 401a, profit sharing plan statements IRA & Roth IRA statements 403b/tax-sheltered account (TSA), thrift savings plan (TSP) statements NON-RETIREMENT ACCOUNTS Bank account statements Photocopies of certificates of deposit Photocopies of savings bonds Employer stock option plan statements Employer stock purchase program statements Brokerage & dividend reinvestment plan account statements Savings/money market account statements Credit union account statements Mutual fund account statements Photocopies of stock or bond certificates not held in accounts TAX-ADVANTAGED ACCOUNTS 529 Accounts Coverdell Education Savings Account statements Uniform Transfer to Minors Account (UTMA/UGMA) statements Health savings account statements Tax-deferred annuity (fixed or variable annuities) statements Physician’s Personal Finance Organizer Page 8 of 17 Other Assets • Place a checkmark beside each kind of asset you own • Do not attach documents for these assets but do give details below. Personal real estate (personal residence, vacation property, raw land, etc.) Investment real estate (rental properties, construction projects, etc.) Vehicles (cars, trucks, boats, trailers, campers, etc.) Personalty (belongings, jewelry, coins, art, musical instruments, antiques, etc.) Money owed you (tax refunds, loans, notes receivable; exclude loans which you do not intend to collect) • In the space below, please give details for assets you checked above. Please be specific (for example “2006 Toyota Land Cruiser”, not “Vehicles”) Description Owner C1 C1 C1 C1 C1 C1 C1 C1 C1 C1 C1 C1 C2 C2 C2 C2 C2 C2 C2 C2 C2 C2 C2 C2 Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Jt/Trust Fair Market Value Physician’s Personal Finance Organizer Page 9 of 17 Organize Your Liabilities Attach These Documents Mortgages & home loans Home equity lines of credit Student loans Auto/vehicle loans Signature or "professional" lines of credit Credit card accounts Other Liabilities (For Which You Have No Documents) Description Owner C1 C1 C1 C1 C1 C1 C1 C1 C1 C1 C2 C2 C2 C2 C2 C2 C2 C2 C2 C2 Jt Jt Jt Jt Jt Jt Jt Jt Jt Jt Balance Payment Rate Contingent Liabilities • If you are a self-employed physician or business owner, you may have “signed for” or personally guaranteed debt for your practice or for investments you may have made (in buildings or equipment holding entities). Please list them below. I know I have personally guaranteed some debt, but I have no idea how much. Description Borrower C1 C1 C1 C1 C2 C2 C2 C2 Balance Physician’s Personal Finance Organizer Page 10 of 17 Organize Your Income • Please give your best estimate of the average monthly income you expect in the next twelve months. Ciient1 Client2 Income (give only pre-tax amounts) Earnings (salary, wages, self-employment, bonus) Alimony/child support received Pension income & Social Security Rental income (net, not gross) Other income: ____________________________ In the foreseeable future, I expect my income to be about the same much higher (explain) much lower (explain) Attach These Documents Last two pay stubs Federal income tax return Employee benefits booklet Employer retirement plan materials (showing contribution limits & matching formulas) Social Security benefit estimate statement (if you were born before 1950) Physician’s Personal Finance Organizer Page 11 of 17 Organize Your Expenses • Please give your best estimate of the average monthly expenses you expect in the next twelve months. I already know the answer to this question: after my federal/state/FICA tax is paid, I spend approximately $___________ per month altogether. (Skip the rest of this section.) Amount Expense (we will calculate income taxes) Alimony/spousal support Auto expense (gas, tires, maintenance) A/B/12= A/B/12= Auto replacement: Client1 buys a $______(A) car every ____(B) years Auto replacement: Client2 buys a $______(A) car every ____(B) years Child care (daycare, nanny, sitter) Child expense (toys, clothing, sports, camp, private school/college, etc.) Child support paid (include schedule/timeframe) Debt payments (cards, vehicles, student loans & consumer debt) Financial advisor, attorney, accountant Gifts & donations (charity, religious, friends, family, holidays, etc) Groceries & dining out Hired help (maid, gardener, driver, etc. but NOT nanny/childcare) House payment (principal & interest only) or rent House payment (taxes & insurance only) Household expense (home improvement, repair, electronics, gardening) Insurance (life, health) Insurance (disability, long term care) Insurance (home, auto & umbrella less homeowner’s included in house payment) Personal (clothing, haircuts, hobbies, habits, spending cash) Medical expenses (doctors, dentists, vision, drugs, etc.) Taxes (Federal, state, FICA) Utilities (electric, water, sewer, trash, gas, phone, cell, cable, internet) Vacations Other expense: _____________________________________ In the foreseeable future, I expect my expenses to be higher lower same. Physician’s Personal Finance Organizer Page 12 of 17 Organize Your Savings Strategies • Please give details about the average monthly savings you are contributing to each of the savings vehicles listed below. Client1 Employer's Roth 401k Employer's Profit sharing plan Traditional IRA Roth IRA 529 account Coverdell Education Savings account UTMA/UGMA or “custodial” accounts Health savings account Tax-deferred annuity (fixed & variable) Bank deposits Employer stock option plan Employer stock purchase program After-tax brokerage/fund account Employer's traditional 401k My employer’s retirement plan has a matching feature Yes No Don’t know /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo Client2 /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo /mo Yes No Don’t know Physician’s Personal Finance Organizer Page 13 of 17 Organize Your Medical Practice Assets • Please give information about your medical practice assets and attach the documents requested below. Medical Practice(s) Description Owner C1 C1 C1 C1 C2 C2 C2 C2 Accounts Receivable Capital Account Balance Medical Office Buildings & Medical Equipment Holding Entities Description Owner C1 C1 C1 C1 C1 C2 C2 C2 C2 C2 % Ownership Valuation or Equity Other Closely-Held Businesses/Stock Description Owner C1 C1 C1 C1 C1 C2 C2 C2 C2 C2 % Ownership Valuation or Equity Attach These Documents (if applicable): Partnership agreements Shareholder agreements Operating agreements Buy-sell agreements Physician’s Personal Finance Organizer Page 14 of 17 Organize Your Risks & Insurance Client1 Client2 I have the following kinds of insurance: Health Auto Homeowner’s / renter’s Disability: long term Disability: short term Life: term Life: cash value, universal or whole life Long term care Umbrella liability Consider Your Risks • Please place a checkmark by each statement that describes your situation. Client1 Client2 I engage in adventure sports (skydiving, mountaineering, scuba diving) I have had more than one traffic ticket in the past two years I own property that sits on a hillside, oceanfront, riverfront, or lowland I serve on a for-profit or non-profit board of directors I use tobacco I have a health issue that may cause me to be uninsurable now or in the future I have a Personal Liability "Umbrella" Policy (PLUP) with a $____ million limit. Attach These Documents (if applicable) Original disability insurance policies, statements & correspondence Original life insurance policies, statements & correspondence Physician’s Personal Finance Organizer Page 15 of 17 Organize Your Charitable Giving • Imagine that you plan to give $100.00 to charity. In the boxes below, please write down the dollar amount you might choose to give to charities in each of the major categories, such that the total of your gifts would equal $100. . .Arts Education Environment Government Health Peace Religion Science Social justice Sports TOTAL GIFTS Hypothetical Gift Amount $100 Please list some of your favorite charities: Physician’s Personal Finance Organizer Page 16 of 17 Organize Your Estate Attach These Documents (if applicable) Will Trust: revocable Trust: irrevocable Durable power of attorney Oregon healthcare directive Death letter/instructions to heirs What legacy do you want to leave to your community, your country or the world? Sign Your Personal Finance Organizer These statements are complete and accurate to the best of my/our knowledge. Signature Client1 Date Signature Client2 Date Physician’s Personal Finance Organizer Page 17 of 17