Legacy Strategies Fact Finder

AG00317-07/09
 PERSONAL INFORMATION
Full name: First _______________________________ Middle _____________________ Last ________________________________________

Occupation: _____________________________________________________________________________________________________________

Date of birth: _______________ Citizenship: ___ US Citizen ___ Resident Alien ___ Non-Resident Alien Are you married? ___ Yes ___ No

Do you smoke? ___ Yes ___ No Current health problems (if any): ___________________________________________________________

Spouse’s full name: First_________________________ Middle _____________________ Last ________________________________________

Occupation: _____________________________________________________________________________________________________________

Date of birth: _______________ Citizenship: ___ US Citizen ___ Resident Alien ___ Non-Resident Alien

Do you smoke? ___ Yes ___ No Current health problems (if any): ___________________________________________________________

Home Address (Principal Residence): _________________________________________________________________________________________

City: ______________________________________________ State _________________________________ Zip _____________________

Phone: (Home) _______________ (Cell) _______________ (Business) _______________ & _______________ (E-mail): ______________________

FINANCIAL ADVISORS
Attorney: ________________________________________________________________ Phone: _________________________ ext. __________

CPA or Accountant: ________________________________________________________ Phone: _________________________ ext. __________

Financial Planner :_________________________________________________________ Phone: _________________________ ext. __________

Broker: _________________________________________________________________ Phone: _________________________ ext. __________

Insurance Agent: _________________________________________________________ Phone: _________________________ ext. __________

Other Advisor: ____________________________________________________________ Phone: _________________________ ext. __________

CHILDREN 1 2 3 4

Name

Date of Birth

Health Status

Child of this marriage? ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No

If no, specify parent ___ You ___ Spouse ___ You ___ Spouse ___ You ___ Spouse ___ You ___ Spouse

Educational Annual Costs

How many years?

GRANDCHILDREN 1 2 3 4 5

Name

Date of Birth

Health Status
Grandchild
___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No
of this marriage?
If no, specify grandparent ___ You ___ Spouse ___ You ___ Spouse ___ You ___ Spouse ___ You ___ Spouse ___ You ___ Spouse

Describe any special concerns, needs or arrangements for children or grandchildren (see page 6 for additional note space):

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WHAT’S IMPORTANT TO YOU AND YOUR FAMILY?
From the following statements, rank your goals from 1 to 5 (1 being the most important). Using the information you provide in this questionnaire, an
analysis can be generated to help you evaluate various strategies to meet your goals. Implementing legacy strategies can help you preserve your
wealth and determine who will receive your assets.
Statement Rank
Provide a financial legacy for your loved ones ________
Provide resources to meet your family’s needs after your death ________
Having sufficient retirement income to provide your desired lifestyle for as long as you and your spouse live ________
Guardianship of and care for minor dependent child(ren), any special needs child(ren) or
other family member(s), i.e., aging parent(s) ________
Leaving a charitable legacy to your house of worship, university or other charitable organization ________

Other __________________________________________________________________________________ ________

PRIOR PLANNING You Spouse

Do You Have a Will? ___ Yes ___ No ___ Yes ___ No
Date Signed

Date of last review

Do You Have a Revocable Living Trust? ___ Yes ___ No ___ Yes ___ No

Date Signed

Date of Last Review

If yes to either

Amount of any Charitable Bequests

How is the Remaining Estate Distributed after Charitable Bequests?

Everything to Surviving Spouse, otherwise to Child(ren) ___ ___

Everything to Child(ren), Grandchild(ren) ___ ___

Trusts are created to take advantage of the applicable credit amount
___ ___
(often called Marital/Family or A-B trusts)
Everything to someone other than surviving spouse ___ (please describe below) ___ (please describe below)

Other ___ (please describe below) ___ (please describe below)

Do you have an Irrevocable Life Insurance Trust?
___ Yes ___ No ___ Yes ___ No
(include policy information on page 4)
Date Signed

Date of Last Review

Amount of Annual Contributions

Amount of Annual Gifts
(exclude amounts to charities, schools & religious organizations)
Have you made gifts that required filing a gift tax return? ___ Yes ___ No ___ Yes ___ No

If yes, total of gifts

Taxes paid on gifts

Notes (see page 6 for additional note space): _________________________________________________________________________________
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 ASSETS AND LIABILITIES
Current Assets and You or Your Spouse or his/her Joint or Community
Current Values Revocable Trust Revocable Trust Property
Checking, Savings
CDs
Stocks & Bonds
Mutual Funds
Money Owed You
Non-Qualified Annuities
Employer Retirement Accounts
If not retired, annual contributions
Traditional IRAs
Roth IRAs
If not retired, annual contributions
*Gross Value of Business Interests
Cars, Boats, Other Vehicles
Personal Belongings, Jewelry
Collectibles
*Total Life Insurance Face Amounts
Other
Total
*Provide details on Page 4
You or Your Spouse or his/her
Current Debts Monthly Payment Joint
Revocable Trust Revocable Trust
Credit Cards
Vehicles
Educational Loans
Personal Loans
Business Loans
Other
Total

Homes & Other Purchase Current Mortgage Monthly **Rental

Ownership
Real Estate Price Value Balance Payment Income
Primary Residence
Second Residence
Vacation Home
Other Real Estate
Property #1
Property #2
Property #3
Property #4
Property #5
Total
Ownership: You or Rev. Trust (Y/YRT); Spouse or Rev. Trust (SP/SPRT); Joint or Community Property (JT)
**Rental Income should be after expenses
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CURRENT ASSETS (cont’d)
Life Insurance You Are The Insured Spouse is The Insured Joint Insureds
Policy #1 - Company
*Owner

Beneficiaries & Relationship

Face Amount
Cash Value (if any)
Premium
Policy #2 - Company
*Owner

Beneficiaries & Relationship

Face Amount
Cash Value (if any)
Premium
Policy #3 - Company
*Owner

Beneficiaries & Relationship

Face Amount
Cash Value (if any)
Premium
*Ownership: You or Rev. Trust (Y/YRT); Spouse or Rev. Trust (SP/SPRT); Joint or Community Property (JT); Irrevocable Life Insurance Trust (ILIT)

Business/Farm Business #1 Business #2

Name of Business
**Type of Business Entity
Owner of Business
Percentage Owned
Are other owners family members?
Describe the business
Your Cost
Fair Market Value of your %
Estimated Growth Rate
What do you want to happen to business/farm:
If you are disabled?
At your retirement?
At your death?
Do you have a buy sell agreement?
If yes, is it funded with life insurance?
Amount of insurance
Ownership: You or Rev. Trust (Y/YRT); Spouse or Rev. Trust (SP/SPRT); Joint or Community Property (JT)
**Type of Business Entity: Sole Proprietor; C-Corp; S-Corp; LLC; Partnership

Notes (see page 6 for additional note space): __________________________________________________________________

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 SALARY (W-2), 1099 (SCHEDULE C) INCOME AND OTHER BUSINESS INCOME

Please Enter Annual Amount You Spouse

Employer Name
Job Title
Current Salary & Bonus
Avg. Annual Increase (%)
Business Income (S-Corp, LLC, K-1)
Avg. Annual Increase (%)
Schedule C Income (after expenses)
Avg. Annual Increase (%)
Pension Income
Annual Increase (%)
Annuity and IRA Income
Income Payable After Your Death
Non-Qualified Deferred Comp.
Expected Annual Payment
Beginning Age
Duration
Other Income

RETIREMENT INFORMATION

You: Are you currently retired? ___ Yes ___ No If no, desired retirement age: ___________________________________________

At what age do you expect to begin receiving Social Security retirement benefits?_____________________________________________________

Estimated Social Security Benefit: ____________________________________

Spouse: Are you currently retired? ___ Yes ___ No If no, desired retirement age: ___________________________________________

At what age do you expect to begin receiving Social Security retirement benefits?_____________________________________________________

Estimated Social Security Benefit: ____________________________________

LIVING EXPENSES

Current Average Monthly Expenses Estimated Monthly Expenses At Retirement

$ __________ (Normal household expenses and entertainment) $ __________ (Normal household expenses and entertainment)

$ __________ (Mortgages/rent) $ __________ (Mortgages/rent)

$ __________ (Other debt) $ __________ (Other debt)

$ __________ (Insurance, income and property taxes) $ __________ (Insurance, income and property taxes)

$ __________ (TOTAL) $ __________ (TOTAL)

___________ Average annual increase (%) ___________ Average annual increase (%)

TAX INFORMATION
Last tax return filed ____________________ Adjusted Gross Income $ ______________ Total Deductions $_________________

Total Federal Tax Owed $ _______________ Total State Tax Owed $ ________________ Refund (due) $ ____________________

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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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AGENT/REGISTERED REPRESENTATIVE INFORMATION (MUST ALWAYS BE COMPLETED)

Name: _______________________________________________________________________________________________________________

Company Name: _______________________________________________________________________________________________________

Address: _____________________________________________________________________________________________________________

City, State, Zip: ________________________________________________________________________________________________________

Telephone Number:____________________________________________ Cell Number: ___________________________________________

Fax Number: _________________________________________________ Email: ________________________________________________

Broker/Dealer:________________________________________________ Agent Number: _________________________________________

UPON COMPLETION, PLEASE FAX TO THE BUSINESS & ESTATE SOLUTIONS TEAM AT: (727) 299-1728.
LIFE INSURANCE PROFESSIONALS CAN OBTAIN MORE INFORMATION ON LEGACY PLANNING CONCEPTS BY
VISITING THE BUSINESS & ESTATE SOLUTIONS TEAM PAGE OF THE WRL OR TFLIC WEBSITE.

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Life insurance products are issued by Western Reserve Life Assurance Co. of Ohio, Columbus, Ohio, or Transamerica Financial Life
Insurance Company, Purchase, NY. All products may not be available in all jurisdictions. Transamerica Financial Life Insurance
Company is authorized to conduct business in New York. Western Reserve Life is authorized to conduct business in all other states.

Neither the issuing company nor its agents offer tax, accounting or legal advice. For guidance in these areas consult with and rely
solely upon your tax, accounting and legal advisors concerning these matters and your particular situation.

Western Reserve Life Assurance Co. of Ohio Transamerica Financial Life Insurance Company
Home Office: Columbus, Ohio Home Office: Purchase, New York
Administrative Office Address: Administrative Office Address:
570 Carillon Pkwy P.O. Box 5068
St Petersburg, Florida 33716 Clearwater, FL 33758-5068
www.westernreserve.com www.tflic.com/ny

AG00317-07/09