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Questionnaire Step 1 of 9 11% Your InformationToday's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Office: Name:* First Last Preferred Name: Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:*Retired Yes No Actual Planned Year of Retirement Marital Status Single Married/Partnership Spouse / Partner InformationName:* First Last Nickname: Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:*Retired Yes No Actual Planned Year of Retirement Anniversary DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Contact InformationStreet Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Phone (Cell)Phone (Home/Work)Email Spouse / Partner Contact InformationPhone (Cell)Phone (Home/Work)Email Please indicate the primary contact for the household to receive legal disclosures:* Myself My Spouse / Partner Number of ChildrenNumber of GrandchildrenDo you have any health issues?Do you or your spouse have any health issues?Does anyone help you make financial decisions?Do any of your children or grandchildren have any special needs?* Yes No If yes, list below:ChildrenNameAgeState of Residence General InformationDo you have an Accountant? Yes No Do you have a financial Advisor? Yes No If yes, please list their name below: First Last Do you have an Attorney? Yes No If yes, please list their name below: First Last Do you have a Will? Yes No Do you have a Living Will? Yes No Would you like to leave money to your children? Yes No Do you expect to care for a child or parent? Yes No Do you have an umbrella policy? Yes No Do you have a POA for Assets? Yes No Do you have a POA for Health? Yes No Financial Planning ObjectivesIs your current cash flow sufficient and comfortable? Yes No Do you live off interest your investment dollars earn? Yes No Do you anticipate any significant changes in cash flow? Yes No Are you planning any major lifestyle changes? Yes No Do you foresee any purchase greater than $15,000 in the next 3 years? Yes No Do you contribute to a charity? Yes No Do you have a living Trust? Yes No Do you expect to receive an inheritance? Yes No How did you acquire your wealth?What is your risk tolerance? Conservative Moderately conservative Moderate Moderately aggressive Aggressive How involved do you like to be with your investments? If something were to happen to you tomorrow, who do you want taken care of? How would you describe your investment knowledge? (None, limited, average, good, high, expert) Are you more concerned about growing your assets or protecting what you already have? What are your primary concerns for today's visit? Employment HistoryMost Recent / Current CompanyNameOccupationYears Previous EmployerNameOccupationYears Spouse's Employment HistoryMost Recent / Current CompanyNameOccupationYears Previous EmployerNameOccupationYears Real EstateEstimated Value of HomeRemaining Mortgage AmountRental Property ValueRemaining Mortgage of Rental PropertySecond Home ValueRemaining Mortgage Amount of Second HomeLocation of Second Home: OtherRemaining Mortgage of Other Sources of IncomeCurrent Employment Pension Social Security Rental Income Other Spouse's Sources of IncomeCurrent Employment Pension Social Security Rental Income Other Additional Sources of Income QuestionsHow much are your monthly expenses? Does pension continue upon death? Yes No If yes, please place the amount: Is there a pension that hasn't started? Yes No If yes, please place the amount: IRA & Retirement Account InformationIRA & Retirement Account InformationWhere is Account held (Bank, Broker, Employer)TypeOwnerAppr. Value Mutual Funds - Brokerage AccountsMutual Funds - Brokerage AccountsTypeName of InstitutionBalance AnnuitiesAnnuitiesName of CompanyType of AnnuityOriginal InvestmentCurrent ValueOwnershipDate Acquired Bank Accounts, Credit Unions & CD'sBank Accounts, Credit Unions & CD'sName of InstitutionBalanceDue Date Life Insurance/Long-Term Care PoliciesLife Insurance / Long-Term Care PoliciesCompanyTypeFace AmountCash ValueAnnual PremiumInsuredBeneficiary Other Assets / Policies (Stocks / Bonds)Other Assets / Policies (Stocks / Bonds)DescriptionValue Debts (Other than mortgage)Debts (other than mortgage)Type of DebtAmount Additional NotesDateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CommentsThis field is for validation purposes and should be left unchanged. 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