Strategic Blueprint Questionnaire

Strategic Blueprint Questionnaire
Instructions: Thank you for engaging us to prepare your comprehensive Strategic Blueprint. It is the first step to help you create a road map towards financial independence. The Strategic Blueprint questionnaire is divided into 7 parts:

1.       General Information;

2.       Assessment of Your Priorities and How Well You Are Doing;

3.       Your Current and Future Projected Income and Expenses;

4.       Your Current Average Monthly Cash Flow;

5.       Your Net Worth and Investment Goals;

6.       Your Investment and Retirement Objectives; and

7.       Your Needs Analysis.

Please complete each question to the fullest extent possible – this will allow us to provide more detailed and personalized recommendations. The more detailed the information you provide, the more valuable this Strategic Blueprint will be. We estimate that the questionnaire should take between 30 and 45 minutes to complete – but rest assured, it will be time well spent. If you cannot complete the questionnaire at one sitting, just click to save your progress at the end of the part you are currently completing, and commence where you left off at a later time.

We find that it is helpful to have your most recent income tax returns and a list of your current assets, liabilities, monthly cash inflows, and monthly cash outflows available to refer to while you are completing this questionnaire.

If you have any questions regarding any questions, please email Angie O’Dea at angie.odea@providentcpas.com. With that, let’s begin!
What is your first and last name?*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
In what state do you reside?*
What is your date of birth?*

MonthDayYear
Date
Are you married?*

YesNo
What is your spouse’s first and last name? *

First NameLast Name
What is your spouse’s date of birth? *

MonthDayYear
Date
Spouse Phone Number*
Please enter a valid phone number.
Do you have children?*

YesNo
How many children do you have?*
What are their names and Date of birth?*
(Important) If we were meeting 3 years from today, what would we be discussing both personally and professionally that would make you happy with your progress. Please list your top 5 goals for the next three years.
Please list your top 5 goals:*
What do you see as the biggest challenges that would keep you from achieving your 3-year goals? Please list your 5 biggest challenges:
Please list your 5 biggest challenges:*
What are the biggest opportunities available that you want to take advantage of to achieve your three-year goals? Please list your 5 biggest opportunities:
Please list your 5 biggest opportunities:*
What is your definition of “financial independence.”*
Have you read "The Richest Doctor by David Auer"

YesNo
If you read the book, The Richest Doctor, which Doctor do you feel you are most like currently (check one)?

ElijahSerenaBenjaminIndira
Which Doctor would you like to be in the future (check one)?

ElijahSerenaBenjaminIndira

Part B - Assessment of Your Priorities and How Well You Are Doing
Your Priorities: Please rank the following on a scale of 0 to 5, where 0 is of the least importance and 5 is of the most importance.
Minimizing taxes.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Having an accurate reporting of my personal and business income and expenses.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Having a clearly defined plan to have enough money in retirement. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Having sufficient savings incase of an emergency and to fund all of my future financial/investment goals. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Being free from high interest debt. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Protecting your wealth in the event of death, disability, or unwanted creditors*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Concerning Tax Mitigation: Please rank the following statements on a scale of 0 to 5, where 0 means you least agree and 5 means you most agree with the statement.
I believe I am utilizing all available personal, investment, and business tax savings strategies available under the tax law. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have a tax advisor who is an expert in tax strategies that apply to high income taxpayers.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have a tax advisor who teaches me ways to proactively reduce my taxes.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
My tax saving strategies are regularly updated and aligned with your personal, financial, and retirement planning goals.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have an equal balance between tax-deferred, tax-free, and long-term capital gain investments.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Concerning Accounting and Bookkeeping: Please rank the following statements on a scale of 0 to 5, where 0 means you least agree and 5 means you most agree with the statement.
I know how much you spend each month.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I track all of my personal income and expenses in real time or at least monthly.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I track all of my business income and expenses in real time or at least monthly.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I track all of my investment performance and net worth in real time or, at least, monthly.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I rebalance my investment portfolio based upon my retirement timeline and risk tolerance on at least a quarterly basis.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Concerning Retirement Planning: Please rank the following statements on a scale of 0 to 5, where 0 means you least agree and 5 means you most agree with the statement.
I have a clearly defined retirement plan and am on track to retire at a specific age.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have calculated the amount of wealth from my investments to fund a specific lifestyle amount during retirement that will not exceed 4% of my investible net worth.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have taken into account unexpected expenses that may occur during retirement, such as health care, long-term care, or caring for a loved one.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I understand how to diversify my investments am confident in my long-term financial plan.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I am comfortable managing my own retirement investments.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Concerning Savings: Please rank the following statements on a scale of 0 to 5, where 0 means you least agree and 5 means you most agree with the statement.
I have at least 6 months in cash or money market reserves to cover expenses in the event of any emergency.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I am saving and investing at least 15% of my gross income for retirement. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I am saving enough to cover the cost of pre-retirement expenses, such as children’s college education/weddings and a vacation home.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have adequate disability insurance to replace at least 70% of your lifestyle expenses if you became incapacitated. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Between my investible investments and life insurance proceeds, my family’s lifestyle needs and additional future expenses would be covered based on 4% of my then-available assets in the event of my death. *

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Concerning Debt Elimination: Please rank the following statements on a scale of 0 to 5, where 0 means you least agree and 5 means you most agree with the statement.
I pay off any high-interest credit card balances each month.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
To the extent I have a mortgage loan, I have a written plan to pay it off within 10 years or less.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
To the extent I have student loan debt, I have a written plan to pay it off within 7 years or less.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I make it a priority to pay off my highest interest loans as fast as possible.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have at least one line of credit available in case of an emergency.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
Concerning Estate and Asset Protection Planning: Please rank the following statements on a scale of 0 to 5, where 0 means you least agree and 5 means you most agree with the statement.
I have a Will that has been updated since my last major life event (i.e., marriage, birth of a child).*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have a revocable living trust and have transferred the title of all of my property into the trust, and the trust has been updated since my last major life event.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have health care and durable general powers of attorney, HIPPA authorizations, and living wills, all of which have been updated since the last major life event.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I wish to leave all my assets to my loved ones and/or charity at the end of my lifetime.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest
I have a family limited partnership, limited liability company, and/or irrevocable trust to protect my assets from unwanted creditors and predators.*

0

1

2

3

4

5

0 is Lowest, 5 is Highest

Part C – Your Current and Projected Future Income and Expenses:
Your Current and Projected Future Income and Expenses: Please complete the following in order to project your 2023, current, and projected future income & expenses over the next 3 years. For 2024 and 2025 Tax Years:

These numbers, even if it is your best estimate, are critical to finding the tax savings and strategies for your benefit!

	2024 You	2024 Spouse	2025 You	2025 Spouse
W-2 Wages and Salaries
Taxable Interest
Qualified Dividends
Ordinary Dividends
Taxable IRA Distributions
Taxable Pensions and Annuities
Taxable Social Security Benefits
Short-Term Capital Gain (Loss)
Long-Term Capital Gain (Loss)
Other Gain (Loss)
Taxable State Income Tax Refund
Alimony Received

INCOME: (Kindly input amount.) IMPORTANT! Completing an accurate and full Strategic Tax Blueprint is dependent on your attention to income and expense tables. Please fill these out to the best of your ability, or your Strategic Tax Blueprint presentation may be delayed. These numbers, even if it is your best estimate, are critical to finding the tax savings and strategies for your benefit! *

	2024	2025
W-2 Wages and Salaries
Taxable Interest
Qualified Dividends
Ordinary Dividends
Taxable IRA Distributions
Taxable Pensions and Annuities
Taxable Social Security Benefits
Short-Term Capital Gain (Loss)
Long-Term Capital Gain (Loss)
Other Gain (Loss)
Taxable State Income Tax Refund
Alimony Received

Sch. C Business/1099 (Kindly input amount.)

	2024 You	2024 Spouse	2025 You	2025 Spouse
Business Gross Revenues
Less Business Deductions

Sch. C Business/1099 (Kindly input amount.)

	2024	2025
Business Gross Revenues
Less Business Deductions

Rental Income (Loss) (Kindly input amount.)

	2024 You	2024 Spouse	2025 You	2025 Spouse
How Many Rental Properties Do You Own, or Plan to Own?
Do You Meet the IRS’ Requirements for Nonpassive Losses? (Yes/No)
Gross Rents
Less Rental Deductions

Rental Income (Loss) (Kindly input amount.)

	2024	2025
How Many Rental Properties Do You Own, or Plan to Own?
Do You Meet the IRS’ Requirements for Nonpassive Losses? (Yes/No)
Gross Rents
Less Rental Deductions

Royalty Income, Partnership Sch. K-1 Income, S Corporation Sch. K-1 Income, Farm Income (Loss) and Unemployment Compensation (Kindly input amount.)

	2024 You	2024 Spouse	2025 You	2025 Spouse
Royalty Income
Partnership Sch. K-1 Income
S Corporation Sch. K-1 Income
Farm Income (Loss)
Unemployment Compensation

Royalty Income, Partnership Sch. K-1 Income, S Corporation Sch. K-1 Income, Farm Income (Loss) and Unemployment Compensation (Kindly input amount.)

	2024	2025
Royalty Income
Partnership Sch. K-1 Income
S Corporation Sch. K-1 Income
Farm Income (Loss)
Unemployment Compensation

Other Income (list the type on the first table and Kindly input amount on the next tables.)

	List Type of Other Income	2024You	2024 Spouse	2025 You	2025 Spouse
.
.
.

Other Income (list the type on the first table and Kindly input amount on the next tables.)

	List Type of Other Income	2024	2025
.
.
.

ADJUSTMENTS TO INCOME (Kindly input amount.)

	2024 You	2024 Spouse	2025 You	2025 Spouse
Educator Expenses
Health Savings Account Deduction
Moving Expenses
Deductible part of SE Taxes
Self-Employed SEP, SIMPLE, and Qualified Plans
Self-Employed Health Insurance Deduction
Penalty on Early Withdrawal of Savings
Alimony Paid
Traditional IRA Deduction
Student Loan Interest Deduction
Tuition and Fees Deduction

ADJUSTMENTS TO INCOME (Kindly input amount.)

	2024	2025
Educator Expenses
Health Savings Account Deduction
Moving Expenses
Deductible part of SE Taxes
Self-Employed SEP, SIMPLE, and Qualified Plans
Self-Employed Health Insurance Deduction
Penalty on Early Withdrawal of Savings
Alimony Paid
Traditional IRA Deduction
Student Loan Interest Deduction
Tuition and Fees Deduction

ITEMIZED DEDUCTIONS:

	2024	2025
Do You Itemize Deductions? (Yes/No)

	2024	2025
If Yes, How Much Itemized Deductions Do You Estimate? (If No, Leave Blank)

For 2026 and 2027 Tax Years:

These numbers, even if it is your best estimate, are critical to finding the tax savings and strategies for your benefit!

	2026 You	2026 Spouse	2027 You	2027 Spouse
W-2 Wages and Salaries
Taxable Interest
Qualified Dividends
Ordinary Dividends
Taxable IRA Distributions
Taxable Pensions and Annuities
Taxable Social Security Benefits
Short-Term Capital Gain (Loss)
Long-Term Capital Gain (Loss)
Other Gain (Loss)
Taxable State Income Tax Refund
Alimony Received

	2026	2027
W-2 Wages and Salaries
Taxable Interest
Qualified Dividends
Ordinary Dividends
Taxable IRA Distributions
Taxable Pensions and Annuities
Taxable Social Security Benefits
Short-Term Capital Gain (Loss)
Long-Term Capital Gain (Loss)
Other Gain (Loss)
Taxable State Income Tax Refund
Alimony Received

Sch. C Business/1099 (Kindly input amount.)

	2026 You	2026 Spouse	2027 You	2027 Spouse
Business Gross Revenues
Less Business Deductions

Sch. C Business/1099 (Kindly input amount.)

	2026	2027
Business Gross Revenues
Less Business Deductions

Rental Income (Loss) (Kindly input amount.)

	2026 You	2026 Spouse	2027 You	2027 Spouse
How Many Rental Properties Do You Own, or Plan to Own?
Do You Meet the IRS’ Requirements for Nonpassive Losses? (Yes/No)
Gross Rents
Less Rental Deductions

Royalty Income, Partnership Sch. K-1 Income, S Corporation Sch. K-1 Income, Farm Income (Loss) and Unemployment Compensation (Kindly input amount.)

	2026 You	2026 Spouse	2027 You	2027 Spouse
Royalty Income
Partnership Sch. K-1 Income
S Corporation Sch. K-1 Income
Farm Income (Loss)
Unemployment Compensation

Royalty Income, Partnership Sch. K-1 Income, S Corporation Sch. K-1 Income, Farm Income (Loss) and Unemployment Compensation (Kindly input amount.)

	2026	2027
Royalty Income
Partnership Sch. K-1 Income
S Corporation Sch. K-1 Income
Farm Income (Loss)
Unemployment Compensation

Other Income (list the type on the first table and Kindly input amount on the next tables.)

	List Type	2026 You	2026 Spouse	2027 You	2027 Spouse
.
.
.

Other Income (list the type on the first table and Kindly input amount on the next tables.)

	List Type	2026	2027
.
.
.

ADJUSTMENTS TO INCOME (Kindly input amount.)

	2026 You	2026 Spouse	2027 You	2027 Spouse
Educator Expenses
Health Savings Account Deduction
Moving Expenses
Deductible part of SE Taxes
Self-Employed SEP, SIMPLE, and Qualified Plans
Self-Employed Health Insurance Deduction
Penalty on Early Withdrawal of Savings
Alimony Paid
Traditional IRA Deduction
Student Loan Interest Deduction
Tuition and Fees Deduction

ITEMIZED DEDUCTIONS:

	2026	2027
Will You Itemize Deductions? (Yes/No)

	2026	2027
If Yes, How Much Itemized Deductions Do You Estimate? (If No, Leave Blank)

For 2028 and 2029 Tax Years:

These numbers, even if it is your best estimate, are critical to finding the tax savings and strategies for your benefit!

	2028 You	2028 Spouse	2029 You	2029 Spouse
W-2 Wages and Salaries
Taxable Interest
Qualified Dividends
Ordinary Dividends
Taxable IRA Distributions
Taxable Pensions and Annuities
Taxable Social Security Benefits
Short-Term Capital Gain (Loss)
Long-Term Capital Gain (Loss)
Other Gain (Loss)
Taxable State Income Tax Refund
Alimony Received

	2028	2029
W-2 Wages and Salaries
Taxable Interest
Qualified Dividends
Ordinary Dividends
Taxable IRA Distributions
Taxable Pensions and Annuities
Taxable Social Security Benefits
Short-Term Capital Gain (Loss)
Long-Term Capital Gain (Loss)
Other Gain (Loss)
Taxable State Income Tax Refund
Alimony Received

Sch. C Business/1099 (Kindly input amount.)

	2028 You	2028 Spouse	2029 You	2029 Spouse
Business Gross Revenues
Less Business Deductions

Sch. C Business/1099 (Kindly input amount.)

	2028	2029
Business Gross Revenues
Less Business Deductions

Rental Income (Loss) (Kindly input amount.)

	2028 You	2028 Spouse	2029 You	2029 Spouse
How Many Rental Properties Do You Own, or Plan to Own?
Do You Meet the IRS’ Requirements for Nonpassive Losses? (Yes/No)
Gross Rents
Less Rental Deductions

Rental Income (Loss) (Kindly input amount.)

	2028	2029
How Many Rental Properties Do You Own, or Plan to Own?
Do You Meet the IRS’ Requirements for Nonpassive Losses? (Yes/No)
Gross Rents
Less Rental Deductions

Royalty Income, Partnership Sch. K-1 Income, S Corporation Sch. K-1 Income, Farm Income (Loss) and Unemployment Compensation (Kindly input amount.)

	2028 You	2028 Spouse	2029 You	2029 Spouse
Royalty Income
Partnership Sch. K-1 Income
S Corporation Sch. K-1 Income
Farm Income (Loss)
Unemployment Compensation

Royalty Income, Partnership Sch. K-1 Income, S Corporation Sch. K-1 Income, Farm Income (Loss) and Unemployment Compensation (Kindly input amount.)

	2028	2029
Royalty Income
Partnership Sch. K-1 Income
S Corporation Sch. K-1 Income
Farm Income (Loss)
Unemployment Compensation

Other Income (list the type on the first table and Kindly input amount on the next tables.)

	List Type	2028 You	2028 Spouse	2029 You	2029 Spouse
.
.
.

Other Income (list the type on the first table and Kindly input amount on the next tables.)

	List Type	2028	2029
.
.
.

ADJUSTMENTS TO INCOME (Kindly input amount.)

	2028 You	2028 Spouse	2029 You	2029 Spouse
Educator Expenses
Health Savings Account Deduction
Moving Expenses
Deductible part of SE Taxes
Self-Employed SEP, SIMPLE, and Qualified Plans
Self-Employed Health Insurance Deduction
Penalty on Early Withdrawal of Savings
Alimony Paid
Traditional IRA Deduction
Student Loan Interest Deduction
Tuition and Fees Deduction

ADJUSTMENTS TO INCOME (Kindly input amount.)

	2028	2029
Educator Expenses
Health Savings Account Deduction
Moving Expenses
Deductible part of SE Taxes
Self-Employed SEP, SIMPLE, and Qualified Plans
Self-Employed Health Insurance Deduction
Penalty on Early Withdrawal of Savings
Alimony Paid
Traditional IRA Deduction
Student Loan Interest Deduction
Tuition and Fees Deduction

ITEMIZED DEDUCTIONS:

	2028	2029
Will You Itemize Deductions? (Yes/No)

Type a question

	2028	2029
If Yes, How Much Itemized Deductions Do You Estimate? (If No, Leave Blank)

Current Average Monthly Cash Flow:

CURRENT AVERAGE MONTHLY INCOME: (Kindly input amount.)

	CURRENT AVERAGE MONTHLY INCOME
Active Income (i.e., W-2, 1099, Sch. C, Partnership, S-Corp)
Portfolio Income (i.e., Interest, Dividends, Royalties)
Passive Net Income (i.e., Rental Real Estate, Private Equity)

CURRENT AVERAGE MONTHLY EXPENSES:(Kindly input amount.)

	CURRENT AVERAGE MONTHLY EXPENSES
Income Taxes
Home Mortgage Payment
Student Loan Payment
Other Loan Payments
Other Living Expenses
Business (if any) Expenses

CURRENT AVERAGE MONTHLY SAVINGS (What type of savings and how much): ie. Total Retirement/Health Savings Account Contributions (describe below)

	What type of savings	How much
.
.
.

CURRENT YEAR RETIREMENT PLAN AVERAGE ANNUAL CONTRIBUTIONS (BY YOU & YOUR SPOUSE AND EMPLOYER-PROVIDED):

Retirement plans, place a check √ on each one you have and then amount if applicable.

	You	Spouse	You (Input $ amount)	Spouse (Input $ amount)
Traditional Individual Retirement Account
Roth (including Backdoor) Individual Retirement Account
401(k)/403(b) Plan – Employee Deferral
401(k)/403(b) Plan – Employer Match
Solo 401(k) Plan
401(h) Plan
Savings Incentive Match Plans for Employees (SIMPLE Plan)
Simplified Employee Pension (SEP)
Salary Reduction Simplified Employee Pension (SARSEP Plan)
Profit-Sharing Plan
Defined Benefit Plan
Money Purchase Plan
457 Plan
Employee Stock Ownership Plan (ESOP)
Restricted Property Trust
Premium-Financed Insurance Plan
Deferred Compensation Plan
Employer Restricted Stock Options
Health Savings Account

Retirement plans, place a check √ on each one you have and then amount if applicable.

	Check if applicable	Amount
Traditional Individual Retirement Account
Roth (including Backdoor) Individual Retirement Account
401(k)/403(b) Plan – Employee Deferral
401(k)/403(b) Plan – Employer Match
Solo 401(k) Plan
401(h) Plan
Savings Incentive Match Plans for Employees (SIMPLE Plan)
Simplified Employee Pension (SEP)
Salary Reduction Simplified Employee Pension (SARSEP Plan)
Profit-Sharing Plan
Defined Benefit Plan
Money Purchase Plan
457 Plan
Employee Stock Ownership Plan (ESOP)
Restricted Property Trust
Premium-Financed Insurance Plan
Deferred Compensation Plan
Employer Restricted Stock Options
Health Savings Account

What Are Any Extraordinary Expenses You Expect to Have Over the Following Time Periods?

	3 months	6 months	12 months	24 months
How much?

Part D – Your Net Worth and Investment Goals
Net Worth: Please complete the following in order to estimate your current approximate net worth.

Cash & Cash Equivalent Savings

	Approximate Current Value
Cash on Hand
Cash in Bank

Cryptocurrency

	Type (i.e., Bitcoin, Ethereum)	Number of Coins	Cost of Coins	Approximate Current Value
.
.
.

Stocks & Bonds

	Description	Number of Shares/Units	Cost Basis	Approximate Current Value
.
.
.

Promissory Notes & Accounts Receivable Owed to You

	Borrower	Interest Rate	Fixed (F) or Variable (V) Rate	Payment Amount	Payment Frequency (i.e., Monthly, Quarterly)	Maturity Date	Current Balance of Note/Receivable
.
.
.

Life Insurance

	Name of Institution	Insurance Type (i.e., term, whole)	Current Death Benefit	Current Cash Surrender Value
.
.
.

Disability Insurance

	Name of Institution	Policy Type (i.e., Group S/T, Personal L/T)	Own Occupation? (Yes/No)	Annual Premium	Benefit Type (i.e., Fixed, % of Income)	Benefit Period (i.e., Monthly, Annual)	Benefit Amount
.
.
.

Retirement Savings

	Your Annual Contribution	Employer Match and Contribution	Approximate Current Value
Traditional IRAs
Roth IRAs
Traditional 401(k) and 403(b)
Roth 401(k) and 403(b)
401(h)
Health Savings Account
Profit-Sharing and 457
Pension and Defined Benefit
Deferred Compensation

Education Savings

	Education Savings Type (i.e., 529, Coverdell, UGMA)	Annual Contribution	Approximate Current Value
.
.
.

Real Estate

	Purchase Price and Improvements	Annual Growth Rate, if Any	Approximate Current Value
Primary Residence
Second/Third Home(s)

Rental Property(ies)

	How Many Properties?	Short-Term or Long-Term Rental?	How Many Hours Per Year on Average Do You Spend on These Properties?	Purchase Price and Improvements	Annual Growth Rate, if Any	Approximate Current Value
Single-Family
Multi-Family
Commercial

Investment Property(ies)

	List if Any	Purchase Price and Improvements	Annual Growth Rate, if Any	Approximate Current Value
.
.
.

Business and/or Partnership Interests

	Name of Business or Partnership	Ownership Percentage	Type (i.e., sole proprietorship, partnership, S-corp)	Investment Amount, if any	Annual Growth Rate, if Any	Approximate Current Value
.
.
.

Other Assets

	Description	Cost	Annual Growth Rate, if any	Approximate Current Value
.
.
.

Student Loans Owed by You

	Lender Name	Interest Rate	Maturity Date	Payment Frequency (i.e., Monthly, Quarterly)	Payment Amount	Current Balance Owed
.
.
.

Mortgage(s)

	Lender Name	Collateral (i.e., Personal Residence, Rental Property)	Interest Rate	Maturity Date	Payment Frequency (i.e., Monthly, Quarterly)	Payment Amount	Current Balance Owed
.
.
.

Other Liabilities

	Lender Name	Collateral (i.e., Personal Residence, Rental Property)	Interest Rate	Maturity Date	Payment Frequency (i.e., Monthly, Quarterly)	Payment Amount	Current Balance Owed
.
.
.

Your Investment and Retirement Objectives: Investment Objectives - Please rate the importance of each item according to the following scale:
Your overall retirement goals*

1

2

3

1 is Low, 3 is High
Minimizing the taxes on your tax-deferred retirement accounts *

1

2

3

1 is Low, 3 is High
Minimizing taxes on an upcoming sale of a highly appreciated investment *

1

2

3

1 is Low, 3 is High
Generating passive streams of income *

1

2

3

1 is Low, 3 is High
Investing in a safe well-diversified portfolio of publicly-traded stocks and bonds *

1

2

3

1 is Low, 3 is High
Investing in alternative investments, such as metals, cryptocurrency, real estate, commodities, private lending, hedge funds,and private equity (including start-ups and angel investments)*

1

2

3

1 is Low, 3 is High
Starting one or more businesses within the next 3 years*

1

2

3

1 is Low, 3 is High
Investing in long-term residential rental property(ies) *

1

2

3

1 is Low, 3 is High
Investing in short-term residential rental property(ies) (i.e., Airbnb.com or VRBO.com) *

1

2

3

1 is Low, 3 is High
Investing in commercial rental property(ies) *

1

2

3

1 is Low, 3 is High
Planning for income for your spouse and/or family in the event of your premature disability or death*

1

2

3

1 is Low, 3 is High
Matching your risk tolerance to that of your investment portfolio *

1

2

3

1 is Low, 3 is High
Protecting your investments from unwanted creditors*

1

2

3

1 is Low, 3 is High
Accumulating an adequate amount of emergency savings*

1

2

3

1 is Low, 3 is High
Saving for children’s future college education*

1

2

3

1 is Low, 3 is High
Saving to make a significant down payment to acquire a personal residence*

1

2

3

1 is Low, 3 is High
Saving to purchase or make a significant down payment on a major asset or investment*

1

2

3

1 is Low, 3 is High
Aggressively paying down high interest debt only *

1

2

3

1 is Low, 3 is High
Aggressively paying down other debt *

1

2

3

1 is Low, 3 is High

Retirement Objectives:*

	How much
What do you expect your average annual growth rate for your overall investments until you retire?
What do you expect your average annual growth rate for your overall investments after you retire?
What do you expect average annual inflation to be?
If you expect to receive an inheritance in the future, approximately how much will it be?
If you expect to receive an inheritance in the future, approximately when will you receive it?
At what age do you plan to retire?

At this time, do you plan to continue to work part-time during retirement?*

YesNo
How much average monthly income from part-time work do you plan to earn?
How many years do you plan to continue working part-time?

Part E – Your Needs Analysis: Please answer the following questions to allow us to know how we may be able to help you.

	Do You Currently Do This?	If You Would Like For Us To Provide This?
Annual Income Tax Return Preparation
Proactive Income Tax Planning
Business Bookkeeping and Financial Statement Preparation
Personal Net Worth and Cash Flow Statement Preparation
Business Entity Structuring Advice
Business Acquisition, Strategic Growth Planning, and Exit Strategy Advice
General Financial Planning Advice
Publicly-Traded Stock and Bond Investment Advice
Alternative Investments Due Diligence and/or Strategic Planning Advice
Long-Term Residential Rental Property Due Diligence and/or Strategic Planning Advice
Short-Term Residential Rental Property Due Diligence Advice and/or Strategic Planning Advice
Commercial Rental Property Due Diligence Advice and/or Strategic Planning Advice
Retirement Planning Advice
Life Insurance Planning Advice
Disability Insurance Planning Advice
Liability Insurance Planning Advice

Other than your individual tax return what other business tax returns would you like us to prepare on your behalf?*

	Name of business	Type of tax return (ie. 1120S, 1065, etc.)
.
.
.
.
.

Kindly list existing entities you have

	Name of entity
.
.
.
.
.

What You Are Looking For in an Advisor?*

Part F - Conclusion: Thank you for completing your Strategic Blueprint Questionnaire.
To better help us improve our clients’ experience, would you please complete the following survey?

YesNo
Should be Empty:

Strategic Blueprint Questionnaire

Part B - Assessment of Your Priorities and How Well You Are Doing

Part C – Your Current and Projected Future Income and Expenses:

Part D – Your Net Worth and Investment Goals

Part E – Your Needs Analysis: Please answer the following questions to allow us to know how we may be able to help you.

Part F - Conclusion: Thank you for completing your Strategic Blueprint Questionnaire.