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Questionnaire (1) Step 1 of 4 25% Contact InformationYour Name:* Your First Name Your Last Name Your Preferred Name: Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Working At/Retired From: Current/Former Occupation: Retired Yes No Marital Status Single Married/Partnership Spouse / Partner InformationPartner's Name:* Partner's First Name Partner's Last Name Partner's Preferred Name: Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Working At/Retired From: Current/Former Occupation: Retired Yes No Home Number:Cell Number:Email Street 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 SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about us? FamilyChildrenNameAgeGrandchildren Age ChildrenNameAgeGrandchildren Age ChildrenNameAgeGrandchildren Age ChildrenNameAgeGrandchildren Age ChildrenNameAgeGrandchildren Age Who are your trustees and/or executor? Do any of your children or grandchildren have special needs? Yes No Are any of your children or grandchildren listed as joint owners? Yes No ConcernsWhich 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 catastrophic illness Outliving nest egg Uncertainty about stock market Leaving a legacy to children and/or grandchildren Need direction with 401K and/or IRA accounts Additional InformationIf you are not already retired, when do you want to retire? How did you acquire your wealth? Who else do you rely on for financial advice and decisions? If something were to happen to you tomorrow, who do you want taken care of ? Please pick the top two for your retirement “nest egg” money. SAFETY LIQUIDITY GROWTH INCOME How would you describe your investment knowledge? NONE AVERAGE LIMITED GOOD HIGH EXPERT Do you have any expectations not listed above? Your Health Partner's Health Who is your current financial advisor? Risk Tolerance Conservative Moderately Conservative Moderate Moderately Aggressive Aggressive Life EventsIn the near future I expect to: (Please check all that apply) Buy a home Sell a home Improve a home Retire Care for a parent Start/Expand a business Pay off debt Start a part-time job Help fund education costs for a family member Sell a property Receive an inheritance Purchase a property Other IncomePlease list monthly income from each source:Social SecurityYouPartner PensionYouPartner (Survivor Options)YouPartner WagesYouPartner Other IncomeYouPartner Are these amounts net or gross? Gross Net How much are your monthly expenses? Is your current cash flow sufficient and comfortable? Yes No Do you take any withdrawals from your retirement savings to meet your current budget? 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 $20,000 within the next 3 years? Yes No Don't Know Do you contribute to a charity? Yes No InvestmentsPlease check off the accounts you currently hold, note the approximate value and bring in the latest statement.Assets Bank / Credit Union Accounts CDs Mutual Funds / Stocks / Bonds Brokerage Accounts Business Interest Annuities Retirement Accounts from Work IRAs / 401K / 403B / Keoghs / TSPs Life Insurance Cash Value Promissory Notes / Contract for Deed Other Assets PropertyHome ValueBalance OwedPaymentPay off date Autos and Personal PropertyBalance OwedPaymentPay off date Additional Properties? Yes Rental/Add’l PropertiesBalance OwedPaymentPay off date InsuranceWhich of the following do you have?Umbrella Policy Yes No Long Term Care Insurance Yes No Have you prepaid your funeral? Yes No Death Benefit Type Whole Term Universal Life Insurance InheritanceWhich of the following documents do you have?Will Yes No Power of Attorney (POA) Assets Yes No Power of Attorney (POA) Health Yes No Living Will Yes No Living Trust Yes No Date Last Updated MM slash DD slash YYYY Income TaxWho files your annual taxes? Bring in copies of the last 2 year’s tax returns.Roth conversion strategy? Account distribution strategy? Tax Goals CommentsThis field is for validation purposes and should be left unchanged. Δ
