Retirement Questionnaire

Deschutes Investment Consulting LLC

Retirement Plan Consulting and Wealth Management
RETIREMENT ASSISTANCE QUESTIONNAIRE
To:*
401(k) Plan Participant
Date:*

MonthDayYear
Re: Important Notice regarding Investment Advice

To assist you with 401(k) plan investing, we have enlisted the expertise of our consultant, Deschutes Investment Consulting LLC, to assist you in planning for retirement.

Before you utilize these services, please read the following notice.

You acknowledge and understand that this client profile questionnaire is a general guide for allocating 401(k) plan investments. In addition, you acknowledge that in making recommendations, Deschutes is a Registered Investment Advisor (RIA) and is acting independently of the plan. The plan or its representatives do not specifically approve/disapprove of the suggestions made by the RIA. The Plan is intended to operate under the guidelines and protections of ERISA Section 404(C). (For a full description of 404(c), please refer to your summary plan description (SPD)).

This financial analysis compares your investments and savings strategy with your financial priorities and concerns. It provides a broad, general guideline that may help shape your financial thinking about investment objectives and risk tolerance. The reports and graphs depend on the quality and accuracy of the data you supply.

Calculations illustrating investment performance are estimates only. Past performance is not a guarantee of future results. This analysis is for estimating purposes only and must be reviewed periodically. Your accountant and attorney should be consulted regarding legal and tax implications. A current prospectus should be read carefully when considering any investment securities.

No liability is assumed resulting from the use of this information contained in this analysis. You ultimately assume responsibility for your financial decisions, and it is important to revise your plans periodically in light of your experiences and changing goals.
Print Name:*
Date:*

MonthDayYear
Personal Information:
Name:

First NameLast Name
Birth Date:*

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Title
Income:*
Preferred Email:*
example@example.com
Preferred Phone Number:*
Please enter a valid phone number.

Spouse/Partner:
Birth Date:

MonthDayYear
Employer:
Title:
Income:
Preferred Email:
Preferred Phone Number:
Please enter a valid phone number.

Insurance/Estate Information
1. Disability Insurance

YesNo
2. Long Term Health Care

YesNo
4. Updated Will

YesNo
5. Expected Inheritances

YesNo

Liabilities
1. Type
Balance $
Rate %
Payment $
Term $
2. Type
Balance $
Rate %
Payment $
Term $
3. Type
Balance $
Rate %
Payment $
Term $
4. Type
Balance $
Rate %
Payment $
Term $

401k Information
1a. When would you like to retire? *
Fill in the age you would like to retire
1b. When would your spouse like to retire?
Fill in the age you would like to retire
2. How much do you think you would like to spend during retirement?
(per year after tax)
3a. What is your current 401k account balance?
3b. What is your spouses current 401k account balance?
4. How much are you deferring, per month, to your 401k?
5. How much is your employer contributing to your 401k?
6. How much are you currently saving (per month) for retirement outside of your 401(k)?
7. What are your other sources of retirement income? (rental income, pensions, etc.)
8. If you know your Social Security Benefits Estimate at full retirement age please provide it below. Optional: Please Attach your latest social security statement or retrieve your estimate online at www.ssa.gov/estimator.

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Investments

9. Tell us about your investments (IRAs, CDs, rental properties, etc.). Optional: Please provide copies of recent statements if you would like us to review your investments.
A. Investment Type
(IRAs, CDs, rental properties, etc.)
Investment Balance
Recent Statement

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B. Investment Type
(IRAs, CDs, rental properties, etc.)
Investment Balance
Recent Statement

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C. Investment Type
(IRAs, CDs, rental properties, etc.)
Investment Balance
Recent Statement

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D. Investment Type
(IRAs, CDs, rental properties, etc.)
Investment Balance
Recent Statement

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E. Investment Type
(IRAs, CDs, rental properties, etc.)
Investment Balance
Recent Statement

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Additional Information
Retirement Goals:
(tell us about your retirement goals - travel, second home, etc.)
Additional Notes:
Privacy Notice
Like other professionals who advise on personal financial matters, we are required to inform our clients of our policies regarding the privacy of client information.

In providing our clients with certain advice, we may receive nonpublic personal financial information from our clients, their accountants, and other representatives, such as financial statements, tax, income information, and other personal financial information. All nonpublic personal information we receive regarding our clients or former clients is held in strict confidence under our professional obligations and is not released to people outside the Firm except with your consent or as required by law or to explain our actions to professional organizations that we are members of.

We may share certain information with non-affiliated third parties who assist us in providing our services to you (such as administrative and client service functions) or marketing services to advise you of our services, subject to the obligation of these third parties not to use or disclose such information for any other purpose.

We retain records relating to our professional services to better assist you with your professional needs and, in some cases, to comply with professional guidelines. We maintain physical, electronic, and procedural safeguards to guard your nonpublic personal information against unauthorized disclosure.

Our company’s business practices are described in our firm’s Form ADV Part 2. If you would like a current copy of this disclosure document, please call or write, and we will be happy to send you one.

If your financial situation, goals, risk tolerance, or investment time horizon has changed since you last spoke with us, please contact us immediately. We need to know the details of your financial life to provide you with the individualized expert services you have come to expect from us.
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Deschutes Investment Consulting LLC

RETIREMENT ASSISTANCE QUESTIONNAIRE

Personal Information:

Investment Information

Insurance/Estate Information

Liabilities

401k Information

Investments

Additional Information

Privacy Notice