Form No. - (To be filled in by FPSB India) Candidate’s Name 2 FPSBI No. Candidate’s Signatures Education Provider Mode of Registration Name of the Education Provider Self Study Please send the completed form to: Financial Planning Standards Board India (FPSB India) 702, 7th Floor, Leela Business Park Andheri Kurla Road, Andheri East Mumbai - 400059 Financial Planning Standards Board India Issue 01/24.10.2011 Rev 00/24.10.2011Name Birth Date City Gender Male | Female | Marital Status Single | Married | State Government Sector Homemaker Total Earning Years ‘Spouse’s Employment Statu: Number of Dependents|_1 Profile Private Sector Others Self Employed Please specify Yes [xe ] 6 of Dependents Relationship Age L Relationship Age Father Child-1 Mother Child-27 Brother ‘Spouse | Child-37 Sister Below Rs. 5 Lakh Between Rs. 7.5 Lakh and Rs. 10 Lakh Between Rs, 15 Lakh and Rs. 20 lakh Self-occupied House Business Premises Financial Planning Standards Board India ‘Two-wheeler Additional House Between Rs. 5 Lakh and Rs. 7.5 Lakh Between Rs. 10 Lakh and Rs. 15 lakh Above Rs. 20 Lakh Land Car Issue 01/24.10.2011 Rev 00/24.10.2011VI. Type of Financial Assets Owned Fixed Deposits Bonds Mutual Funds Pension Fund PPF Provident Fund Vil. Thsuiranee Policies Held (Lite msurance) Endowment Policy Child Plan VIII. Tnsuiranee Policies Held (Non-Life insurance) Vehicle Insurance Business Insurance Disability Insurance |_] Unit Linked Insurance (ULIP) Term Plan Household’s Policy Professional Indemnity Critical illness insurancel_] ‘Stocks/Shares Others (Please specify) Unit Linked Pension| Health Insurance| Accident cover Category Loan amount ‘(Rupess) | Tenure of Loan (No. of Years) EMP (Rupees) Loans Housing Loan Vehicle Loan Education Loan Personal Loan Credit Cards/Other Loans * EMI: Equated Monthly Installments (Amount in Rupees) Other Liabli S, Total Estimated cost ‘Amount Already Accumulated Marriage(Self/Dependents) Hospilalization/Medical ‘Any Other (please specify) Financial Planning Standards Board India 3 Issue 01/24.10.2011 Rev 00/24.10.2011