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Confidential Financial Questionnaire Form
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Contact Information
*
Name
*
Nickname
*
Date of Birth
*
Working At/Retired From
*
Current/Former Occupation
*
Retired?
Yes
No
Semi
Are you currently:
*
Married
Divorced
Widow
Single
*
Spouse Name
*
Nickname
*
Date of Birth
*
Working At/Retired From
*
Current/Former Occupation
*
Retired?
Yes
No
Semi
*
Primary Address
*
City
*
Home Phone
*
Cell Phone
*
Email Address
Family
No Child
How many children do you have?
1
2
3
4
5
6
Child 1
*
Child’s names and ages
*
No. of Grandchildren
*
GrandChild Name and age
Child 2
*
Child’s names and ages
*
No. of Grandchildren
*
GrandChild Name and age
Child 3
*
Child’s names and ages
*
No. of Grandchildren
*
GrandChild Name and age
Child 4
*
Child’s names and ages
*
No. of Grandchildren
*
GrandChild Name and age
Child 5
*
Child’s names and ages
*
No. of Grandchildren
*
GrandChild Name and age
Child 6
*
Child’s names and ages
*
No. of Grandchildren
*
GrandChild Name and age
Do any of your children or grandchildren have special needs?
*
Yes
No
Are any of your children or grandchildren listed as joint owners on any of your accounts/assets?
*
Yes
No
Legal Items
Which of the following legal documents do you have in place?
Will
Power of Attorney (POA) Assets
Power of Attorney (POA) Health
Living Will
Living Trust
Additional Items
Which of the following do you have in place?
*
Umbrella Policy
Yes
No
*
Long Term Care Insurance
Yes
No
*
Do you have life insurance?
Yes
No
*
Death Benefit
*
Type
Whole
Term
Universal
Cash Flow
Please list monthly income from each source.(If not required then put 0)
Social Security
*
Husband
*
Spouse
Pension
*
Husband
*
Spouse
Survivor Options
*
Husband
*
Spouse
Wages
*
Husband
*
Spouse
Other Income
*
Husband
*
Spouse
Are these amounts net or gross?
*
Gross
Net
*
How much are your monthly expenses?
Here are some common expenses: Mortgage, Food, Gas, Car Loan, Insurance, Utilities Gifts/Donations, Medical, Taxes, Social Security etc.
Is your current cash flow sufficient and comfortable?
*
Yes
No
Don't Know
Do you live off interest your investment dollars earn?
*
Yes
No
Don't Know
Do you anticipate any significant changes in cash flow?
*
Yes
No
Don't Know
Are you planning any major lifestyle changes?
*
Yes
No
Don't Know
Do you foresee any large purchases greater than $5,000 within the next 3 years?
*
Yes
No
Don't Know
Do you contribute to a charity?
*
Yes
No
Life Events
*
In the near future I expect to: (Please check all that apply.)
Buy a home
Care for a parent
Help fund education costs for a grandchild
Sell a home
Start/ Expand a business
Sell a property
Improve a Home
Pay off a debt
Receive an inheritance
Retire
Start a part-time job
Purchase a property
Other
Assets
Assets:
*
Please check off the accounts you currently hold and bring the latest statement in for your visit.
Bank / Credit Union Accounts
*
Total Value
Annuities
*
Total Value
Mutual Funds / Stocks / Bonds
*
Total Value
IRAs/401k/Keoghs/TSAs
*
Total Value
Brokerage Accounts
*
Total Value
Life Insurance
*
Total Value
Retirement Accounts from Work
*
Total Value
Long Term Care Insurance
*
Total Value
CD's ance
*
Total Value
Promissory Notes / Contract for Deed
*
Total Value
Business Interest
*
Total Value
Other Assets
*
Total Value
Property:
*
Home Value
*
Auto(s) Value
*
Invest Properties Value
Liabilities:
*
Mortgage Loan
*
Auto Loans
*
Add'l Debt
Additional Information
*
If you are not already retired, when do you want to retire?
*
How did you acquire your wealth?
*
Are you concerned with picking the right Medicare plan?
*
What is most important about your money to you?
*
If something were to happen to you tomorrow, who do you want taken care of?
*
Are you more concerned about growing your assets or protecting what you already have?
Concerns
*
Which of the following are your top three concerns?
Losing too much money in the stock market
Avoid paying too much in taxes
Considering retirement and not sure if I/we can afford to
Not having a reliable income plan for retirement
Concerned about giving away life savings due to a Long Term Care Event
Outliving nest egg
Uncertainty about stock market
Leaving a legacy to children and/or grandchildren
Need direction with 401k and/or IRA accounts
Financial Objective
How would you describe your investment knowledge?
*
None
Average
Limited
Good
High
Expert
*
What are your Financial Objectives? (check all that apply)
Income Now
Guarantees provided
Growth Potential
Estate Planning
Tax-Deferred Growth
Pass Assets to Beneficiaries
Other
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