DISCLOSURE STATEMENT AND TERMS OF AGREEMENT

The Pacific American Retirement and Financial Planning Analyzer collects information about you that is used by representatives of Pacific American Securities and Pacific American Advisors, both subsidiaries of Pacific American Services Group, as a source of facts that are used in the preparation of an individual Financial Plan. The calculations and assumptions, as well as the recommendations for certain courses of action included in the Financial Plan that you will receive are based primarily on the information that you provide in the Pacific American Retirement and Financial Planning Analyzer; and also on certain projections, estimates, variables and formulas that have been broadly established and are widely believed to represent sound economic theories. However, the calculations and assumptions, and the recommendations for certain courses of action, are purely forecasts and cannot be guaranteed. Past performance is not a guarantee of future results.

In utilizing the information provided in the Pacific American Retirement and Financial Planning Analyzer and in the preparation and providing of your individual Financial Plan, neither Pacific American Advisors, Pacific American Securities or Pacific American Services Group is acting as an investment advisor or as a fiduciary for purposes of the Employee Retirement Income Security Act of 1974 (ERISA).

I acknowledge that I have completely read the Disclosure Statement and Terms of Agreement above and that I understand and agree to its contents and disclosures

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Signature of appoval

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Date

Are You Retiring In The Next Six Months?: __ Yes __ No

Do You Wish To Roll Assets Into An IRA At Retirement?: __ Yes __ No

Current Employer: __________________________________
Street Address: ____________________________________
Unit/Suite Number: ____
City: ______________________
State: ___________
Zip/Postal Code: _________ - _____
Phone: ( ___ ) - ___ - ______
Title: ___________________
Annual Salary: $ _____________
Years Employed: ___
Projected Retirement Age: ___
Primary Source of Income (Select One): Investments Compensation Retirement Assets
Tax Filing Status: Single Married Filing Jointly Married Filing Separately Head of Household

Invested In Stocks: Yes No

If Yes, Enter The Year You Began: ______

Invested In Bonds: Yes No

If Yes, Enter The Year You Began: ______

Invested In Commodities: Yes No

If Yes, Enter The Year You Began ______

Invested In Options: Yes No

If Yes, Enter The Year You Began: ______

Investment Objectives: __ Growth __ Current Income __ Tax Deferral __ Liquidity
(Please rank from 1 to 4 by priority, with 1 indicating highest priority and 4 indicating lowest priority.)

Risk Tolerance (Select One): Aggressive Moderate Conservative

Do Your Investment Objectives Allow Speculation: Yes No

Check here if you have a spouse:

About your spouse (If Applicable):

Last Name: _________________________
First Name: _________________________
Date of Birth (mm/dd/yy): __ / __ / __

Current Employer: __________________________________
Street Address: ____________________________________
Unit/Suite Number: ____
City: ______________________
State: ___________
Zip/Postal Code: _________ - _____
Phone: ( ___ ) - ___ - ______
Title: ___________________
Annual Salary: $ _____________
Years Employed: ___
Projected Retirement Age: ___

ASSETS AND LIABILITES

Investment Assets:

Taxable - Money Market, Savings, Fixed Income
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Stocks and Equities
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Tax-Free / Municipal Bonds
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Variable Annuities
Your Current Balance: ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Fixed Annuities
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Nonqualified Employer Sponsored Plans
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Real Estate
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Limited Partnerships
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Businesses
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Insurance - Cash Value
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Other (Please Indicate Type): ________________
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Please enter additional investment assets below:
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Retirement Assets:

Traditional IRA
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Roth IRA
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

SIMPLE IRA
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

SEP-IRA
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Keogh
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

401(k)
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Profit Sharing
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Money Purchase
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

403 (b)
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

ESOP
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Other (Please Indicate Type): ________________
Your Current Balance: $ ________________
Your Spouse's Current Balance (If Applicable): $ ________________

Please enter additional retirement assets below:
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Assets Saved for Educational Purposes:
(Please only list assets that are saved for educational purposes in you or your spouse's name.)

Taxable - Money Market, Savings, Fixed Income Current Balance: $ ________________
Stocks and Equities Current Balance: $ ________________
Tax-Free / Municipal Bonds Current Balance: $ ________________
Variable Annuities Current Balance: $ ________________
Educational IRA: $ ________________

Savings Information:

Your Projected Annual Savings From Investment Assets: $ ________________
Your Projected Annual Savings From Retirement Assets: $ ________________

Liability Information:

Credit Card Debt
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Margin Debt
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Personal Loan
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Other Short Term Debt (Please Indicate Type): ________________
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Home Mortgage
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Investment Real Estate Mortgage
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Auto Loan
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Business Loan
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Other Long Term Debt (Please Indicate Type): ________________
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Please enter additional liabilities below:
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INCOME AND EXPENSE SUMMARY

Anticipated Annual Income Requirement When Retired (current dollar value): $ ________________
Is This Figure: After Tax Dollars Before Tax Dollars
Would You Rather: Use Principal and Interest Maintain Principal

Annual Income:

Your Earned Income: $ ________________
Your Spouse's Earned Income (If Applicable): $ ________________

Your Investment Income: $ ________________
Your Spouse's Investment Income (If Applicable): $ ________________

Your Spousal/Child Support: $ ________________
Your Spouse's Spousal/Child Support (If Applicable): $ ________________

Your Rents and Royalties: $ ________________
Your Spouse's Rents and Royalties (If Applicable): $ ________________

Other Income (Please Indicate Source): $ ________________
Your Total: $ ________________
Your Spouse's Total (If Applicable): $ ________________

Monthly Expense Items:

Food (Groceries): $ ________________

Housing Expenses:

Housing Payments/Lease/Rent: $ ________________

Real Estate Taxes: $ ________________

Homeowner's/Renter's/Insurance: $ ________________

Utilities: $ ________________

Telephone/Communications: $ ________________

Housing Repair/Maintenance: $ ________________

Other Housing Expenses: $ ________________

Transportation Expenses:

Motor Vehicle Loan/Lease Payment: $ ________________

Motor Vehicle Insurance: $ ________________

Motor Vehicle Gasoline/Oil: $ ________________

Motor Vehicle Repair/Maintenance: $ ________________

Other Transportation Expenses: $ ________________

Other Expenses:

Clothing/Personal: $ ________________

Medical/Dental/Health Care Related: $ ________________

Credit Card Payments: $ ________________

Other Loan Payments: $ ________________

Insurance (Life/Health/Disability): $ ________________

Entertainment/Gifts: $ ________________

Savings/Investments: $ ________________

Income Taxes: $ ________________

Social Security Taxes: $ ________________

Other Expenses: $ ________________

Social Security:

Are you eligible for Social Security benefits: Yes No

If yes, at what age will you start to receive benefits: ___

Estimated benefit amount: $ ________________
(If unsure, we will estimate your benefit based on your annual income.)

Is your spouse eligible for Social Security benefits (If Applicable): Yes No

If yes, at what age will your spouse start to receive benefits (If Applicable): ___

Estimated benefit amount (If Applicable): $ ________________
(If unsure, we will estimate your benefit based on your annual income.)

Pension / Lump Sum Benefit

Does your current employer supply you with an annual pension at retirement: Yes No
If yes, what is your estimated pension payment amount: $ ________________

Is the pension subject to a cost of living adjustment: Yes No
At what age will you be eligible to receive this pension: ___
For how many years will payments be made (please enter L for lifetime payments): ___
In the event of death, what percent of the pension is the your spouse entitled to: ___ %

Does your spouse's current employer supply him/her with an annual pension at retirement (If Applicable): Yes No
If yes, what is your spouse's estimated pension payment amount (If Applicable): $ ________________

Is your spouse's pension subject to a cost of living adjustment (If Applicable): Yes No
At what age will your spouse be eligible to receive this pension (If Applicable): ___
For how many years will payments be made (please enter L for lifetime payments): ___
In the event of his/her death, what percent of your spouse's pension are you entitled to (If Applicable): ___ %

Are you anticipating a lump sum distribution from a pension plan at retirement: Yes No
If yes, at what age will this lump sum pension payment become available: ___
What is the amount of the payment: $ ________________

Is your spouse anticipating a lump sum distribution from a pension plan at retirement (If Applicable): Yes No
If yes, at what age will this lump sum pension payment become available (If Applicable): ___
What is the amount of the payment (If Applicable): $ ________________

Inflows / Outflows:

Please provide information about any significant one time cash inflows or outflows that your or your spouse (if applicable) currently have planned. Significant inflows would be things like the sale of property or an inheritance. Significant outflows would be things like a vacation or college tuition for you or your spouse.

Type: Inflow Outflow
For: You Your Spouse
Description: _______________________________________________________
Year: ___
Amount: $ ________________
Is the amount taxable (if inflow) or reportable (if outflow): Yes No

Please enter additional inflows or outflows below:
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INVESTMENT PROFILE

Answers to these questions are used to determine the risk level to which you are most suited. The recommendations we make regarding asset allocation will be influenced to a great degree by the level of risk that your answers to these questions suggest is most appropriate.

How many dependents will rely on you for financial support over the next five years:

None
One
Two
Three
Four or more

Your compensation is likely to increase at the following annual rate:

Decline
Stay The Same
Increase With Inflation
Increase 0-4% Over Inflation
Increase More Than 4% Over Inflation

What is your current investment timeframe:

0-2 Years
3-5 Years
6-8 Years
9 Years Or More

What is your current investment timeframe for college (If Applicable):

0-2 Years
3-5 Years
6-8 Years
9 Years Or More

Your current liquid savings and investments would allow you to pay your living expenses for:

Less Than 3 Months
3-6 Months
6-12 Months
1-2 Years
More Than 2 Years

You are more comfortable knowing that you have a guaranteed fixed rate of return, rather than the possibility of a much higher yet also possibly lower rate of return, in the future:

Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree

You would be comfortable investing in a company that has generated no real revenues, based solely on the company's perceived potential to capitalize on proprietary or groundbreaking technologies:

Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree

It is most important to you that you:

Avoid Losses
Keep Pace With Inflation
Keep Pace With The Stock Market
Outperform The Stock Market

If you could see a potentially higher rate of return in exchange for accepting greater volatility in some or all of your investments, you would accept:

More Volatility With Most Of Your Money
More Volatility With Some Of Your Money
Some Volatility With Most Of Your Money
Some Volatility With Some Of Your Money
No More Volatility With Any Of Your Money

Imagine that in January of last year you invested $10,000 in a stock, which, by the end of the year, had increased in value to $13,000. This gain is roughly equal to gains experienced by the stock market and the stock is still considered a good investment, so what do you do:

Sell Part Of The Investment And Lock In Part Of The Gain
Sell The Whole Investment And Take Your Full Gains
Buy More Of The Stock For Your Portfolio
Do Nothing

If a $10,000 investment began to decline in value during the first year, but the fundamentals of the company remained the same, at what level would you sell the stock and put the money in a more stable investment:

$9,500
$9,000
$8,500
$8,000
I Would Not Sell

SERVICE PROFILE

PLEASE INDICATE WHICH OF THE FOLLOWING SPECIFIC ADDITIONAL TYPES OF ANALYSIS YOU WOULD LIKE US TO PERFORM AND THEN SUPPLY THE REQUESTED INFORMATION FOR EACH SECTION APPEARING BELOW:

1) Retirement Plan Distribution Analysis

If you would like Pacific American Advisors to include in your completed Financial Plan recommendations regarding your distribution options from a qualified retirement plan, please indicate here.

What is the birth date of your oldest beneficiary: _____________
(If no beneficiary, please check this box )

Beneficiary is (If Applicable): Spouse Someone Other Than Spouse

Age Payouts Are To Begin (If Applicable):

Current Account Value or Total Amount of Distribution (If Applicable): $

PLEASE INDICATE WHICH OF THE FOLLOWING APPLIES TO YOU AND THEN SUPPLY THE REQUESTED INFORMATION FOR THE SECTION(S) APPEARING BELOW:

a) I am about to receive a distribution from a retirement plan.

You will receive a Qualified Plan Distribution Analysis if you select option a. The Qualified Plan Distribution Analysis will compare your various distribution alternatives.

b) I am under the age 59 *.

You will receive a Substantially Equal Payment Analysis if you select option b. The Substantially Equal Payment Analysis will provide advice regarding penalty free withdrawals from your IRA.

c) I am between the ages of 59 * and 70 *.

You will receive a Normal Distribution Analysis if you select option c. The Normal Distribution Analysis will demonstrate the effect of a series of withdrawals from your IRA on your IRA balance.

d) I am over the age 70 *.

You will receive a Required Minimum Distribution Analysis if you select option d. The Required Minimum Distribution Analysis will present a calculation of your minimum distribution requirements.

2) Estate Planning

If you would like Pacific American Advisors to include in your completed Financial Plan a basic estate and trust analysis and recommendations regarding estate planning and estate taxes, please indicate here.

Do you have a will: Yes No

Does your spouse have a will (If Applicable): Yes No

Are you a citizen of the United States: Yes No

Is your spouse a citizen of the United States (If Applicable): Yes No

What is your remaining estate tax exemption: $

What is your spouse's remaining estate tax exemption (If Applicable): $

EXISTING TRUSTS

Please provide information regarding trusts that have been established to date by you, your spouse, or jointly.

For: You Your Spouse Joint

Current Value: $

Type of Trust:

Marital Trust
Credit Shelter Trust
Q-TIP Trust
Irrevocable Life Insurance Trust

Trust Source:

Taxable - Money Market, Savings, Fixed Income
Stocks and Equities
Tax Free / Municipal Bonds
Annuities
Other

Retained Growth Rate: %
(The retained growth rate is the percentage of the trust's total return that is not distributed each year. For example, if a trust had a total rate of return of 8%, and paid out 2% of that return, the retained growth rate would be 6%.)

Check here if you have additional existing trusts:

PLANNED GIFTING

Please provide information regarding any gifts you or your spouse or both plan to give to family, charities or friends.

Gift From: You Your Spouse Joint

Gift Description:

Gift Amount: $

Gift Recipient:

Start Year:

Stop Year:

Gift Type:

Taxable - Money Market, Savings, Fixed Income
Stocks and Equities
Tax Free / Municipal Bonds
Annuities
Other

Check here if you have additional planned gifts:

3) Education Planning

If you would like Pacific American Advisors to include in your completed Financial Plan an education planning analysis, please indicate here.

VALUE OF ASSETS IN A CHILD'S NAME

Please provide information regarding assets that are invested in a UGMA/UGTA in a child's name, or in the name of a trust. Make sure you only enter information regarding assets that are in a child's name here. Indicate the value of investments for education purposes made in your name in your general asset listing above.

Child's First Name:

Desired Educational Institution:

Years Until Attendance:

Years Of Attendance:

Total Taxable--Money Market, Savings, Fixed Income: $

Total Stocks and Equities: $

Total Tax-Free / Municipal Bonds: $

Total Annuities: $

Total Educational IRA: $

Check here if you have other children

OTHER FUNDING

Please provide information about any significant one time cash inflows you or your spouse (if applicable) expect to use for educational purposes. Significant inflows for this purpose would be things like the sale of property, an inheritance or gifts.

Funding Source:

Year:

Amount: $

Is the amount: Before Tax After Tax

Check here if you have other sources of funding

Please Read the Statement Below Before Submitting Form

The Pacific American Retirement and Financial Planning Analyzer collects information about you that is used by representatives of Pacific American Securities and Pacific American Advisors, both subsidiaries of Pacific American Services Group, as a source of facts that are used in the preparation of an individual Financial Plan. The calculations and assumptions, as well as the recommendations for certain courses of action included in the Financial Plan that you will receive are based primarily on the information that you provide in the Pacific American Retirement and Financial Planning Analyzer; and also on certain projections, estimates, variables and formulas that have been broadly established and are widely believed to represent sound economic theories. However, the calculations and assumptions, and the recommendations for certain courses of action, are purely forecasts and cannot be guaranteed. Past performance is not a guarantee of future results.

In utilizing the information provided in the Pacific American Retirement and Financial Planning Analyzer and in the preparation and providing of your individual Financial Plan, neither Pacific American Advisors, Pacific American Securities or Pacific American Services Group is acting as an investment advisor or as a fiduciary for purposes of the Employee Retirement Income Security Act of 1974 (ERISA).

If you agree with the above conditions, please sign below and fax to:
1-877-552-9833

______________________________________
Signature

____________
Date