Financial Planning Questionnaire

1
Client #1
First Name
Last Name
2
Date of Birth
Date
Month
Day
Year
3
Employment and Income
Occupation and Employer
Annual Earned Income
4
Client # 2 Name
First Name
Last Name
5
Date of Birth
Date
Year
Month
Day
6
Employement and Income
Occupation and Employer
Annual Earned Income
7
Marital Status
Single
Married or Common laws
Divorced
Widowed
8
Depedents
9
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Phone Number
Please enter a valid phone number.
11
Email
example@example.com
12
Primary Financial Goals
Retirement Planning
Education Funding
Estate Planning
Insurance Planning
Investment Review
Other
13
Describe your goalShort Term (0-2 years)
14
Describe your goalMedium Term (3-5 years)
15
Describe your goalLong-term Goal (5+ years)
16
Client # 1Occupation and Income
Occupation
Annual Income
17
Client # 2Occupation and Income
Occupation
Annual Income
18
Rental Income
19
Investment IncomeInterests, Dividends
20
Any Other IncomeCommission, loyality, spousal support
21
Essential Household ExpensesNot including Mortgage Payments
House hold essential expenses: all utility, property tax, auto lease, gas and insurance
Please enter a number
Please Select
Please Select
Per month
Per Year
Per month or per year
22
Personal Expenses Not including Mortgage Payments
Food, Meal and enterainment, education, any personal purchase
Please enter a number
Please Select
Please Select
Per month
Per Year
Per month or per year
23
Lifestyle expensesTravel
Cost of travel or major purchase
24
Any other expenses not mentioned aboveFor example
25
Investment Accounts #1
Type of Account: Non-Registered, RSP, TFSA
Please enter a account balance
26
Investment Accounts #2
Type of Account: Non-Registered, RSP, TFSA
Please enter a account balance
27
Investment Accounts #3
Type of Account: Non-Registered, RSP, TFSA
Please enter a account balance
28
Real Estate Assets
29
Real Estate Liablity
30
Other Debts and Liablity
31
Other
32
Life Insurance
33
Disability, Critical Illness or Long Term Care Insurance
34
File UploadPlease submit your Investment Statements
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35
Additional Comments
36
I authorize the Financial Planning Firm to use the information provided in this questionnaire to develop a personalized financial plan. I understand that this plan will be based on the accuracy and completeness of the information I have provided.
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Signature
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