Confidential Questionnaire

Confidential Questionnaire
The purpose of this financial questionnaire is to
assemble a summary view of your financial picture which we will use to
develop the best possible strategy for you and your goals. While you do
not have to answer every question (you can leave anything blank that you
choose), it is important to be as thorough as possible to ensure that
any options we discuss are appropriate for your unique situation.

**All information is strictly Confidential**
Personal and Family Information
Your Full Name
Date of Birth
Spouse (Full Name)
Date of Birth
Child #1
Date of Birth
Child #2
Date of Birth
Child #3
Date of Birth
Child #4
Date of Birth

Primary Residence
Home Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Email Address
example@example.com

Income

Occupation, Income, and Income Tax Rates
Your Position
Employer
Work Phone
Please enter a valid phone number.
Current Base Salary $
Annual Increase %
Annual Bonus $
Spouse (Position)
Employer
Work Phone
Please enter a valid phone number.
Current Base Salary $
Annual Increase %
Annual Bonus $
Current Effective Income Tax Rate %
Retirement Effective Tax Rate %
Expected Inflation Rate %
Approximate Credit Score

Defined Benefits (Social Security, PERs, Railroad Pension, etc.)
Defined Benefits
Defined Benefits
Defined Benefits
Defined Benefits

Other Future Income or Assets (Inheritance, Sale of Business, etc.)
Future Income / Assets
Future Income / Assets
Future Income / Assets

Real Estate and Mortgages
Primary Residence
2nd Residence
Other Real Estate

Qualified Retirement Accounts (IRA, Roth, 401k, SEP, Deffered Comp, Pension Balances, Etc.)
Qualified Retirement Account
Qualified Retirement Account
Qualified Retirement Accounts
Qualified Retirement Accounts
Qualified Retirement Account
Qualified Retirement Account

Savings and Investment Accounts (CD's, Securities, Bonds, Mutual Funds, ETF's, Annuities, etc.)
Savings and Investment Account
Savings and Investment Account
Savings and Investment Account
Savings and Investment Account
Savings and Investment Account
Savings and Investment Account

Liabilites

Installment Loans (Auto, Boat, RV, Student/Parent College, HELOC. Etc.)
Installment Loan
Installment Loan
Installment Loan
Installment Loan

Revolving Credit Lines (Credit Cards, Store Charge Cards, Checking Credit Lines, Etc.)
Revolving Credit Line
Revolving Credit Line
Revolving Credit Line
Revolving Credit Line

Protection

Life Insurance (Term, Cash Value)
Life Insurance
Life Insurance
Life Insurance
Life Insurance

Other Insurance (Auto, Home-Owners, Renters, Umbrella, Health, Disability, Long Term Care, Etc.)
Other Insurance
Other Insurance
Other Insurance
Other Insurance
Other Insurance
Other Insurance
Other Insurance
Wills or Living Trust

Expenses

Future Expenses (College, Weddings, Etc.)
Future Expenses
Future Expenses
Additional Comments:
(Other factors that could be important to your Financial Position)

Please bring the following to your first meeting:
Other:
Insurance Policy not listed
Other:
Insurance Policy not listed

I have received the above checked documents for review and they will be kept confidential in a place of safe keeping.
Type a question

Clear
Date
Representing
Should be Empty: