Personal Financial Planning

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Personal Information

Primary taxpayer, spouse/partner details, and dependents.

Primary Taxpayer

First Name *

Middle Name / Initial

Last Name *

Suffix

Date of Birth *

Social Security Number

Filing Status

Citizenship Status

Home Phone

Cell Phone

Email Address *

Home Address

City, State, ZIP

Years at This Address

Employer / Company

Occupation / Job Title

Years at Current Employer

Spouse / Partner (if applicable)

First Name

Middle Name / Initial

Last Name

Date of Birth

Social Security Number

Cell Phone

Email Address

Citizenship Status

Employer / Company

Occupation / Job Title

Years at Current Employer

Dependents

Include all qualifying children and other dependents.

Full Name	Relationship	Date of Birth	SSN (optional)	Full-Time Student?	Claimed on Return?
						✕

Step 1 of 8

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Income Sources

All annual income — use most recent tax year figures.

Earned Income

Taxpayer W-2 Wages

Spouse W-2 Wages

Self-Employment / 1099 Income

Self-Employed / Business Owner?

Yes No

If Yes — Business Name / EIN

Investment & Passive Income

Interest Income

Dividend Income

Capital Gains / Losses

Rental / Real Estate Income

Other Income

Social Security Benefits

Pension / Annuity

Alimony Received

Other Income

Describe Other Income Sources

Prior Year Total Income (for comparison)

Step 2 of 8

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Employment Benefits

Employer-provided benefits, retirement plans, and health coverage.

Retirement Plan Contributions

Taxpayer 401(k)/403(b) Contribution

Taxpayer Employer Match %

Spouse 401(k)/403(b) Contribution

Spouse Employer Match %

Taxpayer Vesting Schedule

Spouse Vesting Schedule

Stock Compensation?

Yes No

If Stock Comp — Describe (type, vesting date, approx. value)

Health & Flex Benefits

Health Insurance Type

Annual Health Premium

Annual Deductible

FSA Contribution?

Yes No

FSA Annual Amount

Dependent Care FSA?

Yes No

Step 3 of 8

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Assets & Investments

All personal assets at current approximate market value.

Cash & Liquid Assets

Checking Account(s)

Savings Account(s)

Money Market / CDs

Cash Value — Life Insurance

Retirement Accounts

401(k)/403(b) — Taxpayer

401(k)/403(b) — Spouse

IRA / Roth IRA — Taxpayer

IRA / Roth IRA — Spouse

SEP-IRA / SIMPLE IRA

Pension / Defined Benefit

HSA Balance

Annuities (Surrender Value)

Taxable Investments

Brokerage / Investment Account(s)

529 / Education Savings

Crypto / Digital Assets

Real Estate & Physical Assets

Primary Residence (Market Value)

Investment / Rental Properties

Vehicles (Market Value)

Business Ownership Interest

Personal Property / Valuables

Other Assets

Investment Account Detail (institution, account type, approx. balance)

Step 4 of 8

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Liabilities & Debts

All outstanding debts and obligations at current balance.

Debt Summary

Primary Mortgage Balance

Home Equity Loan / HELOC

Investment Property Mortgage(s)

Auto Loan(s)

Student Loan(s)

Credit Card Balances

Personal Loans

Other Liabilities

Loan Detail

Lender / Creditor	Loan Type	Balance ($)	Monthly Payment ($)	Interest Rate %	Maturity Date
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Step 5 of 8

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Insurance & Estate Planning

Life, disability, property coverage, and estate planning documents.

Life Insurance Policies

Insured	Policy Type	Insurer	Death Benefit ($)	Cash Value ($)	Annual Premium ($)	Beneficiary
							✕

Disability & Other Insurance

Homeowner's / Renter's Annual Premium

Auto Insurance Annual Premium

Umbrella / Excess Liability?

Yes No

Umbrella Coverage Amount

Step 6 of 8

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Retirement Planning & Tax History

Retirement goals, Social Security, pension projections, and prior year tax matters.

Retirement Goals

Desired Retirement Age (Taxpayer)

Desired Retirement Age (Spouse)

Desired Monthly Retirement Income

Planning Life Expectancy (age)

Social Security Est. Benefit at FRA (Taxpayer)

Social Security Est. Benefit at FRA (Spouse)

Planned SS Claiming Age

Pension / Defined Benefit Expected (Taxpayer)

Pension / Defined Benefit Expected (Spouse)

Retirement Vision / Additional Notes

Step 7 of 8

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Goals, Documents & Authorization

Top financial concerns, required documents checklist, and signature.

Top Financial Concerns & Goals

Goal / Concern #1

Topic

Describe in Detail

Goal / Concern #2

Topic

Describe in Detail

Goal / Concern #3

Topic

Describe in Detail

Additional Notes & Special Circumstances

Required Documents Checklist

Tax & Income Documents

Investment, Retirement & Insurance Documents

Estate, Legal & Other Documents

Document Notes

Authorization & Signatures

By signing below, I/we certify that the information provided is accurate and complete to the best of my/our knowledge. I/we authorize R.M. White CPA to use this information solely for the purpose of providing financial planning and tax services. I/we understand this information will be held in strict confidence.

Authorized Signature — Primary Taxpayer

Printed Name

Date

Signature (sign above line)

Authorized Signature — Spouse / Partner (if applicable)

Printed Name

Date

Signature (sign above line)

Signature — Financial Planner / CPA

Printed Name — CPA / Planner

CPA License Number

Date

Engagement Type

Referred By

CPA / Planner Signature

Step 8 of 8

Personal Financial
Planning Intake

Personal Information

Income Sources

Employment Benefits

Assets & Investments

Liabilities & Debts

Insurance & Estate Planning

Retirement Planning & Tax History

Goals, Documents & Authorization

Form Submitted!