Financial Planning Inventory - DB101



-359325611EMPLOYMENT GOAL00EMPLOYMENT GOAL??Wage Employment Monthly Earning Goal ($ /mo): ______________________ Rate of Pay: ??Hourly ??Daily??Monthly??Other: ________________________Pay Frequency: ??Weekly ??Every two weeks ??Twice/month ??Monthly????Other ____________________ Number of hours/week: ______________________________ ??Self-Employment Projected Monthly Profits ($/mo): ___________________Type of Self-Employment: ??Sole proprietorship ??Partnership ??LLC, corporation ??Other Type/Name of Business _____________________________________________________________ Comfort with benefits changing when workingFearful of benefit changes when working. Does not want to disrupt or work off cash benefits.Cautious about benefit changes when working. Wants to work and keep cash benefits. No major concerns about benefit changes when working. May consider working off cash benefits. Wants to work off cash benefits.0378460DEMOGRAPHIC INFORMATION00DEMOGRAPHIC INFORMATIONAddress: __________________________________________________________________________________ City: ______________________________________________ State: _____ Zip Code: ______________ Citizenship StatusUS CitizenQualified AlienOther Legal ResidentUndocumented or Non-immigrantDisability Status??Determined to have a disability by: ??Social Security??State Medical Review Team (SMRT)??Other:_____________________________________________??Determined blind by:??Social Security??State Medical Review Team (SMRT)??Other:_____________________________________________??My disability is pending??I do not have a disability0330200HOUSEHOLD INFORMATION00HOUSEHOLD INFORMATIONLiving SituationExpenses??Own place (alone or with spouse/kids)Pay own expenses? ??Yes??No??Group home/foster care??Monthly rent $_________________ ??With roommates??Rent subsidy $ ________________ ??Homeless??Monthly mortgage$_________________Marital Status??Not married??Married, not living with spouse??Married, living with spouseSpouse’s Income Type:??Wage ??Self-employment ??SSI ??SSDI??Retirement ??Other ________________________ Spouse’s Total Monthly Income Amount: $ ___________________ Spouse’s Total Asset Amount: $ ____________________________(Include things like retirement accounts, life insurance policies, bank accounts, boats, RV’s, etc.)Biological or adopted children under age 18??NoneChild 1 Age: ________ Living With? ??Y ??N Child Support ?Received ?Paid $: _________ Child 2 Age: ________Living With? ??Y ??N Child Support ?Received ?Paid $: _________Child 3 Age: ________Living With? ??Y ??N Child Support ?Received ?Paid $: _________Child 4 Age: ________Living With? ??Y ??N Child Support ?Received ?Paid $: _________Child 5 Age: ________Living With? ??Y ??NChild Support ?Received ?Paid $: _________57150274320OTHER INCOME 00OTHER INCOME Include income the person receives, other than SSI, Title II (SSDI) and state benefits.??Unemployment Insurance $ ___________________ ??Long term or short term disability insurance $ ___________________??Alimony (spousal support) $ ___________________ ??Other: Type__________________________ $ ___________________0331470HEALTH CARE COVERAGE DETAILS00HEALTH CARE COVERAGE DETAILSMedicareFrequency/Use of Part A:??Weekly ??Monthly??Quarterly??Yearly??RarelyFrequency/Use of Part B:??Weekly ??Monthly ??Quarterly??Yearly??RarelyFrequency/Use of Part D:??Weekly ??Monthly ??Quarterly??Yearly??RarelyMedical Assistance (MA)Frequency/Use:??Weekly ??Monthly??Quarterly??Yearly??RarelyTypes of services: ________________________________________________________________________________________________________________________________________________________Other current health care coverage??VA health care coverage??Parent’s employer health care coverage ??Tribal health care coverage ??MNsure plan ??Spouse’s employer sponsored health care ??Individual’s own employer health care??Other __________________________________ If not on MA, would MA coverage be helpful to have? ??Yes ??No Please explain______________________________________________________________________0340360WORK HISTORY00WORK HISTORY Any work in past year? ??Yes??NoIf yes, what? ________________________________________Monthly earnings $_______________________Has all work been reviewed by Social Security? ??Yes??No0330835POTENTIAL WORK INCENTIVES00POTENTIAL WORK INCENTIVESImpairment Related Work Expense (IRWE)Any IRWE expected once employed? ??Yes ??NoPotential IRWE Type: ________________________________ Amount $ _____________________ Potential IRWE Type: ________________________________ Amount $ _____________________ Potential IRWE Type: ________________________________Amount $ _____________________ Any other work-related expenses expected once working? ??Yes ??No Plan to Achieve Self-Support (PASS)Any major costs to achieve employment???Yes ??No If yes, what? ___________________________________________Amount $ _______________________SubsidyExtra help needed or lower production on the job? ??Yes ??No0350520NOTES00NOTESSpecific questions/concerns about benefits/working: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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