FINANCIAL PLANNING DATA COLLECTION FORM

“Discovery consists of looking at the same thing as everyone else does and thinking something different”

- Albert Szent-Gyorgyi, 1937 Nobel Prize Winner

Client Name/s

Adviser

Date of Interview

PRIVATE AND CONFIDENTIAL

Important Notice to Clients

The information requested in this form is necessary to enable a recommendation to be made on a reasonable basis and will be used for that purpose. The Corporations Law requires that recommendations made to clients are consistent with the person’s financial needs and objectives and have a reasonable basis. The adviser must therefore rely on the information supplied and will assume such to be current and accurate.

PERSONAL DETAILS

Client Partner

Title

Given Names

Surname

Preferred Name

DOB

Home Address

Postal Address

Home Phone

Mobile

Fax

Business Phone

Email

Preferred Contact method

TFN

Marital Status

Current State of Health

Smoker

Private Health Insurance

Occupation

Employment Status

Meeting Place

Referred by

DEPENDANTS

Name Sex DOB Support to Age Occupation

THIRD PARTIES

Type Name Company Phone Address

Family Member

Accountant

Solicitor

Insurance Adviser

Other

Other

ASSETS

Assets Date of

Purchase Ownership Purchase Price Current Value Debt on Asset

ADDITIONAL LIABILITIES

Liabilities Lender Owner Balance Interest Rate

(F or V) P&I or

Interest Only Monthly

Repayment Term

INCOME

Client Partner Joint

Gross Salary

Fringe Benefits

Salary Sacrifice

Bonus/Commissions

Centrelink Benefits

Department of Veterans Affairs

Investment Income

Allocated Pension

Annuity

Other Taxable Income

Other Non-Taxable Income

Total Income

EXPENDITURE

Client Partner Joint

Household Expense

Recreation & Education

Transport

Health Insurance Premiums

Loan Payments

Other Expenses

Total Expenses

SURPLUS CASHFLOW

(Income - Expenditure)

INCOME AND EXPENSES SUMMARY

Combined

What is your annual cost of living?

What is your annual combined income?

How much do you save each year?

Do you expect any changes to your income and/or expenses?

If yes, provide details

How much readily accessible money do you need to meet emergencies and your day-to-day expenditure?

Currently how is your surplus used or deficit met?

INVESTMENT EXPERIENCE

What is your time horizon for investments?

What is your Risk Profile? (Refer to Asset Allocation workbook)

Your experience in Property, Shares etc.

PRE-RETIREMENT & RETIREMENT PLANNING

Money is an enabler, given enough money, what do you want to achieve in retirement?

What are your measures of success is Retirement?

What factors can affect your retirement? Do your children have income protection? Do you intend to help with a deposit on a house? What risks are you or your adult children exposed to?

ENVIRONMENTAL, SOCIAL AND ETHICAL CONSIDERATIONS Do you have any environment, social or ethical considerations that need to be taken into account?

FUTURE PLANNED EXPENDITURES

Capital Expenditure Estimated Amount Target Date

$

$

$

$

INVESTMENT PREFERENCES

Rate the importance of the following: Client Partner

Important Neutral Not

Important Important Neutral

Not Important

Flexibility & diversity in investment choice

Need for capital growth

Need for regular income

Automatic asset allocation/rebalance

Greater control & more active management

Desire to minimise costs

Need for liquidity/cash

Capacity to service loans

LIFESTYLE AND FINANCIAL GOALS

What you want to achieve Amount Details Your Instructions

Consolidation/review your Superannuation

$

Address goal now

Ongoing goal Address in ___ years

Not in scope

Cater for lump sum expenses $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Review current investments $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Provide for retirement $

Address goal now

Ongoing goal Address in ___ years

Not in scope

How much do you require in retirement

$

Address goal now

Ongoing goal Address in ___ years

Not in scope

Access Centrelink benefits $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Access a pre-retirement pension $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Ongoing Advice paid for out of your Superannuation/Pension balance

$

Address goal now

Ongoing goal Address in ___ years

Not in scope

LIFESTYLE AND FINANCIAL GOALS

What you want to achieve Amount Details Your Instructions

Consolidate/repay debts $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Borrow to invest $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Maintain a cash reserve $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Build up an Investment Portfolio $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Reduce income tax $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Save for your children’s education

$

Address goal now

Ongoing goal Address in ___ years

Not in scope

Buy or sell shares $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Invest using regular contributions $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Review insurance requirements $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Provide for family in Death, Injury, Illness

$

Address goal now

Ongoing goal Address in ___ years

Not in scope

Other $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Other $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Other $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Other $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Other $

Address goal now

Ongoing goal Address in ___ years

Not in scope

Please attach all relevant documents from your existing Investments, Superannuation funds etc.

ESTATE PLANNING

Do you have current Wills? Yes No

If yes, does it need reviewing? Yes No

Do you have Powers of Attorney? Yes No

If yes, does it need reviewing? Yes No

Do you have a Testamentary Trust? Yes No

Have you made Binding nominations on your Superannuation assets? Yes No

OTHER ISSUES

Do you have Private Health Insurance? Yes No

Are you likely to receive an Inheritance in the future? Yes No

Do you have a Discretionary or Unit Trust? Yes No

Do you have accumulated sick leave? Yes No

If yes, how many days?

CURRENT INSURANCE

Current Personal Insurance (Life Cover, Total & Permanent Disability, Trauma, Whole of Life, Endowment)

Provider Type Policy Number Life Insured Owner Cover Level Premium Retain

$ $ $ Yes/No

$ $ $ Yes/No

$ $ $ Yes/No

$ $ $ Yes/No

$ $ $ Yes/No

$ $ $ Yes/No

What existing Assets would be realised (fully and/or partially) in the event of Death/TPD/Trauma?

Asset Client 1 Client 2 Joint Death TPD Trauma

$ $ $ Yes/No Yes/No Yes/No

$ $ $ Yes/No Yes/No Yes/No

$ $ $ Yes/No Yes/No Yes/No

$ $ $ Yes/No Yes/No Yes/No

$ $ $ Yes/No Yes/No Yes/No

Current Income Protection Insurance

Provider Owner Policy Number Monthly Benefit Premium Waiting Period Benefit Period Retain

Yes/No

Yes/No

Yes/No

Yes/No

Current Business Insurance (Key Person Insurance, Loan Guarantee, Buy/Sell Agreements or Partnership Buyout)

Provider Owner Policy Number Monthly Benefit Premium Waiting Period Benefit Period Retain

Yes/No

Yes/No

Yes/No

Yes/No

INSURANCE NEEDS ANALYSIS

Client 1 Client 2 Joint

In the event of Death

Debts to Extinguish

Proportion of the lost income to replace

Income required

Annual cost per child

Expenses on death – e.g. funeral & legal costs

In the event of Total & Permanent Disability

Debts to Extinguish

Proportion of the income to replace

Income required

Annual cost per child

In the event of Trauma

Debts to Extinguish

Proportion of the income to replace

Income required

Annual cost per child

One off medical/lifestyle cost

Annual medical/lifestyle cost

Client 1 Client 2

In the event of illness or injury

Replace income

Replace portion of Superannuation Guarantee

Do you have an alternative source of income

If yes, provide source

How many months can you go without income

Insurance Features Client 1 Client 2

Death

Buy back

Extend expiry of Life cover

TPD

Buy back

Any or Own occupation

Trauma

Buy back

Re-instatement

Income Protection

Agreed or Indemnity

Preferred waiting period

Other

CPI automatic adjustment

Child benefits

INSURANCE NEEDS ANALYSIS - CONTINUED

Business 1 Business 2

In the event of Business Expenses claim

Debts to Extinguish

Fixed business costs

Staff salaries and superannuation

Costs of a locum

AGREED INSURANCE QUOTES

Quotes Required - Client Quote 1 Quote 2 Quote 3

Life

TPD

Trauma

Income Protection

Business Expenses

Would you like to hold your Life insurance inside or outside of Superannuation? Inside/Outside

Would you like to hold your TPD insurance inside or outside of Superannuation? Inside/Outside

Would you like to hold your Income Protection insurance inside or outside of Superannuation? Inside/Outside

Quotes Required - Partner Quote 1 Quote 2 Quote 3

Life

TPD

Trauma

Income Protection

Business Expenses

Would you like to hold your Life insurance inside or outside of Superannuation? Inside/Outside

Would you like to hold your TPD insurance inside or outside of Superannuation? Inside/Outside

Would you like to hold your Income Protection insurance inside or outside of Superannuation? Inside/Outside

CLIENT ACKNOWLEDGEMENT & ENGAGEMENT AUTHORITY

SUBJECT MATTER

At our meeting, we discussed the goals you are seeking to achieve and the strategy for reaching these goals. As part of the process we discussed your needs, objectives and financial situation and agreed on the following:

e.g. Provide for Retirement, Consolidate you debts etc.

SCOPE OF ADVICE

After identifying the subject matter above we agreed to cover the following areas of advice, as relevant to your circumstances, within an appropriate advice document:

e.g. Superannuation/Pension, Risk Advice etc.

Where the advice is limited, please state reasons for the limitation:

The following matters will not be included as part of the advice document preparation at this time:

ADDITIONAL NOTES

ACKNOWLEDGEMENT

The information provided in this form is complete and accurate to the best of my/our knowledge (except where we have indicated that I/we have chosen not to provide the information).

I/We have read and understood the Securitor Financial Services Guide and Credit Guide part one dated 1st

July 2013, and the adviser profile part two, dated 1

st July 2013, including the section titled ‘Privacy Statement’. I/We agree to Securitor collecting,

using and disclosing my/our personal information in accordance with the Privacy Policy.

I/We understand and acknowledge that the advice given by the adviser will only be appropriate to the extent of the information provided and the needs identified, and that if limited information has been provided and/or limited needs identified, I/we risk making a financial commitment to an investment or product that may not be appropriate to my/our overall investment objectives, financial situation and particular needs.

I/We have informed you if any of the funds available for investment have been borrowed from any source related or unrelated to the advice sought (e.g. home equity loan, margin loan, credit card etc).

I/We will only provide information about other individuals, such as dependants, spouse/partner, guarantors, if those individuals have agreed that I can share that information with you and I will inform them that I/we have provided information about them and make them aware of the information provided in the Privacy Policy.

I authorise the adviser of Atkinson Financial Planning to prepare a Statement of Advice.

I/We agree that: 1. Subject to the authorisation of the preparation of a Statement of Advice, I am/we are to receive the following financial

services from the adviser named in this fact finder (“adviser”) and understand that my/our personal information (including any sensitive information such as health information, membership of professional organisations and sexual preferences and practices (“sensitive information”) is being collected primarily for these purposes:

Retirement Planning;

Estate Planning;

Superannuation;

Investment Planning;

Budgeting;

Managed Investment Schemes;

Life, TPD, Trauma Insurance and Income Protection Insurance;

Gearing;

Direct Equities;

Instalment Warrants;

Banking including credit and debit products;

Arranging for the acquisition and disposal of all relevant products of the type described above; and

An ongoing review service for my/our investment portfolio or life insurance program. Your adviser will only provide you with advice that your adviser is permitted to offer you.

2. I/We also consent to the disclosure of my/our personal information (including my/our sensitive information):

To organisations involved in providing my/our adviser with marketing services and to their service providers (for example posting services), so that my/our adviser may offer me/us products and services that might meet my/our financial needs; and to other organisations in connection with the sale or proposed sale of all or part of the adviser’s business and to the use of that personal information by those organisations for those purposes.

3. I/We also consent to the collection of my personal information for the purpose of my adviser providing the services stated above. This consent also relates to my sensitive information.

4. If I/we have provided personal information about an individual (such as a partner, dependant, employer, or accountant) I/we have or will as soon as practicable, provide the individual with a copy of the Privacy Notification Statement (PNS) that was provided to me with the Financial Services Guide and made them aware that the PNS applies to their personal information that has been collected for the purpose of my adviser providing me/us with the financial advice I/we have requested.

5. If I/we have provided sensitive information about someone else, I/we have or will obtain the consent of that person to that information being collected by my adviser and my adviser’s service providers.

6. I/We consent to receive updated versions of the Financial Services guide (FSG) and Adviser Profile via email.

Delete any item or consent in paragraphs 1 to 5 above which you do not agree with.

Client Name Client Signature Date

Partner Name Partner Signature Date

Adviser Name Adviser Signature Date

IDENTIFICATION FORM

INDIVIDUALS & SOLE TRADERS

GUIDE TO COMPLETING THIS FORM

o Complete one form for each individual. Complete all applicable sections of this form in BLOCK LETTERS.

o Contact your licensee if you have any queries.

SECTION 1A: PERSONAL DETAILS

Surname Date of Birth dd/mm/yyyy

Full Given Name(s)

Residential Address (PO Box is NOT acceptable)

Street

Suburb State Postcode Country

COMPLETE THIS PART IF INDIVIDUAL IS A SOLE TRADER

Full Business Name (if any) ABN (if any)

Principal Place of Business (if any) (PO Box is NOT acceptable)

Street

Suburb State Postcode Country

SECTION 1B: VERIFICATION PROCEDURE

Verify the individual’s full name; and EITHER their date of birth or residential address.

o Complete Part I (or if the individual does not own a document from Part I, then complete either Part II or III.)

o Contact your licensee if the individual is unable to provide the required documents.

PART I – ACCEPTABLE PRIMARY ID DOCUMENTS

Tick

Select ONE valid option from this section only

Australian State / Territory driver’s licence containing a photograph of the person

Australian passport (a passport that has expired within the preceding 2 years is acceptable)

Card issued under a State or Territory for the purpose of proving a person’s age containing a photograph of the person

Foreign passport or similar travel document containing a photograph and the signature of the person*

PART II – ACCEPTABLE SECONDARY ID DOCUMENTS – should only be completed if the individual does not own a document from Part I

Tick

Select ONE valid option from this section

Australian birth certificate

Australian citizenship certificate

Pension card issued by Centrelink

Health card issued by Centrelink

Tick

AND ONE valid option from this section

A document issued by the Commonwealth or a State or Territory within the preceding 12 months that records the provision of financial benefits to the individual and which contains the individual’s name and residential address

A document issued by the Australian Taxation Office within the preceding 12 months that records a debt payable by the individual to the Commonwealth (or by the Commonwealth to the individual), which contains the individual’s name and residential address. Block out the TFN before scanning, copying or storing this document.

A document issued by a local government body or utilities provider within the preceding 3 months which records the provision of services to that address or to that person (the document must contain the individual’s name and residential address)

If under the age of 18, a notice that: was issued to the individual by a school principal within the preceding 3 months; and contains the name and residential address; and records the period of time that the individual attended that school

PART III – ACCEPTABLE FOREIGN ID DOCUMENTS – should only be completed if the individual does not own a document from Part I

Tick

BOTH documents from this section must be presented

Foreign driver's licence that contains a photograph of the person in whose name it issued and the individual’s date of birth*

National ID card issued by a foreign government containing a photograph and a signature of the person in whose name the card was issued*

*Documents that are written in a language that is not English must be accompanied by an English translation prepared by an accredited translator.

SECTION 1C: RECORD OF VERIFICATION PROCEDURE

IMPORTANT:

Attach a legible copy of the ID documentation used to verify the individual (and any required translation).

Alternatively, if agreed between your licensee and the product issuer, complete the ID Document Details below, and DO NOT attach copies of the ID Documents.

ID DOCUMENT DETAILS Document 1 Document 2

Verified From Original Certified Copy Original Certified Copy

Document Issuer

Issue Date

Expiry Date

Document Number

Accredited English Translation

N/A Sighted N/A Sighted

SECTION 1D: FINANCIAL PLANNER DETAILS – identification and verification conducted by:

Date Verified (dd/mm/yyyy)

Financial Planner’s Name Phone No. 03 9841 7755

AFS Licensee Name Securitor AFSL No. 240687

IDENTIFICATION FORM

INDIVIDUALS & SOLE TRADERS

GUIDE TO COMPLETING THIS FORM

o Complete one form for each individual. Complete all applicable sections of this form in BLOCK LETTERS.

o Contact your licensee if you have any queries.

SECTION 1A: PERSONAL DETAILS

Surname Date of Birth dd/mm/yyyy

Full Given Name(s)

Residential Address (PO Box is NOT acceptable)

Street

Suburb State Postcode Country

COMPLETE THIS PART IF INDIVIDUAL IS A SOLE TRADER

Full Business Name (if any) ABN (if any)

Principal Place of Business (if any) (PO Box is NOT acceptable)

Street

Suburb State Postcode Country

SECTION 1B: VERIFICATION PROCEDURE

Verify the individual’s full name; and EITHER their date of birth or residential address.

o Complete Part I (or if the individual does not own a document from Part I, then complete either Part II or III.)

o Contact your licensee if the individual is unable to provide the required documents.

PART I – ACCEPTABLE PRIMARY ID DOCUMENTS

Tick

Select ONE valid option from this section only

Australian State / Territory driver’s licence containing a photograph of the person

Australian passport (a passport that has expired within the preceding 2 years is acceptable)

Card issued under a State or Territory for the purpose of proving a person’s age containing a photograph of the person

Foreign passport or similar travel document containing a photograph and the signature of the person*

PART II – ACCEPTABLE SECONDARY ID DOCUMENTS – should only be completed if the individual does not own a document from Part I

Tick

Select ONE valid option from this section

Australian birth certificate

Australian citizenship certificate

Pension card issued by Centrelink

Health card issued by Centrelink

Tick

AND ONE valid option from this section

A document issued by the Commonwealth or a State or Territory within the preceding 12 months that records the provision of financial benefits to the individual and which contains the individual’s name and residential address

A document issued by the Australian Taxation Office within the preceding 12 months that records a debt payable by the individual to the Commonwealth (or by the Commonwealth to the individual), which contains the individual’s name and residential address. Block out the TFN before scanning, copying or storing this document.

A document issued by a local government body or utilities provider within the preceding 3 months which records the provision of services to that address or to that person (the document must contain the individual’s name and residential address)

If under the age of 18, a notice that: was issued to the individual by a school principal within the preceding 3 months; and contains the name and residential address; and records the period of time that the individual attended that school

PART III – ACCEPTABLE FOREIGN ID DOCUMENTS – should only be completed if the individual does not own a document from Part I

Tick

BOTH documents from this section must be presented

Foreign driver's licence that contains a photograph of the person in whose name it issued and the individual’s date of birth*

National ID card issued by a foreign government containing a photograph and a signature of the person in whose name the card was issued*

*Documents that are written in a language that is not English must be accompanied by an English translation prepared by an accredited translator.

SECTION 1C: RECORD OF VERIFICATION PROCEDURE

IMPORTANT:

Attach a legible copy of the ID documentation used to verify the individual (and any required translation).

Alternatively, if agreed between your licensee and the product issuer, complete the ID Document Details below, and DO NOT attach copies of the ID Documents.

ID DOCUMENT DETAILS Document 1 Document 2

Verified From Original Certified Copy Original Certified Copy

Document Issuer

Issue Date

Expiry Date

Document Number

Accredited English Translation

N/A Sighted N/A Sighted

SECTION 1D: FINANCIAL PLANNER DETAILS – identification and verification conducted by:

Date Verified (dd/mm/yyyy)

Financial Planner’s Name Phone No. 03 9841 7755

AFS Licensee Name Securitor AFSL No. 240687