Questionnaire Questionnaire Step 1 of 9 11% Your InformationToday's Date* MM DD YYYY Office:Name:* First Last Nickname:Date of Birth* MM DD YYYY Age:*RetiredYesNoActual Planned Year of Retirement MM DD YYYY Marital StatusSingleMarried/PartnershipSpouse / Partner InformationName:* First Last Nickname:Date of Birth* MM DD YYYY Age:*RetiredYesNoActual Planned Year of Retirement MM DD YYYY Anniversary Date MM DD YYYY 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland 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?*YesNoIf yes, list below:ChildrenNameAgeState of Residence General InformationDo you have an Accountant?YesNoDo you have a financial Advisor?YesNoIf yes, please list their name below: First Last Do you have an Attorney?YesNoIf yes, please list their name below: First Last Do you have a Will?YesNoDo you have a Living Will?YesNoWould you like to leave money to your children?YesNoDo you expect to care for a child or parent?YesNoDo you have an umbrella policy?YesNoDo you have a POA for Assets?YesNoDo you have a POA for Health?YesNo Financial Planning ObjectivesIs your current cash flow sufficient and comfortable?YesNoDo you live off interest your investment dollars earn?YesNoDo you anticipate any significant changes in cash flow?YesNoAre you planning any major lifestyle changes?YesNoDo you foresee any purchase greater than $15,000 in the next 3 years?YesNoDo you contribute to a charity?YesNoDo you have a living Trust?YesNoDo you expect to receive an inheritance?YesNoHow did you acquire your wealth?What is your risk tolerance?ConservativeModerately conservativeModerateModerately aggressiveAggressiveHow 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 EmploymentPensionSocial SecurityRental IncomeOtherSpouse's Sources of IncomeCurrent EmploymentPensionSocial SecurityRental IncomeOtherAdditional Sources of Income QuestionsHow much are your monthly expenses?Does pension continue upon death?YesNoIf yes, please place the amount:Is there a pension that hasn't started?YesNoIf 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)DsecriptionValue Debts (Other than mortgage)Debts (other than mortgage)Type of DebtAmount Additional NotesCommentsThis field is for validation purposes and should be left unchanged.