Pre-Appointment Form

Pre-Appointment Form
We are looking forward to getting together with you. If you have any questions or require assistance prior to your visit, please call our office at 309.263.1333.

Please bring the following items with you to your visit:
- All brokerage firm statements
- All life insurance and annuity policies
- All IRA and retirement account statements
- Tax returns for the past two years
- Social Security Statement (download at https://www.ssa.gov/myaccount/statement.html)
CONTACT INFORMATION
Name
First:
Last:
Nickname (if applicable):
Date of Birth:

MonthDayYear
Date
Current/Former Employer:
Current/Former Job Title:
Retired?

YesNoSemi
Cell Phone:
Email Address:
example@example.com
Spouse Name
First:
Last:
Nickname (if applicable):
Date of Birth:

MonthDayYear
Date
Current/Former Employer:
Current/Former Job Title:
Spouse Retired?

YesNoSemi
Cell Phone:
Email Address:
example@example.com
Home Phone:
Street Address 1:
Street Address 2:
City:
State/Province/Region:
Postal Code:
Country:
Were you referred to us?

YesNo
Who referred you?
FAMILY
Number of Children:
Number of Grandchildren:
Do any of your children or grandchildren have special needs?

YesNo
Are any of your children or grandchildren listed as joint owners on any of your accounts/assets?

YesNo
Family Notes
Legal Items
Which of the following legal documents do you have in place? (check all that apply)

Will(s)Powers of Attorney (POA) – AssetsPowers of Attorney (POA) – HealthLiving WillLiving Trust
Which of the following items do you have in place? (check all that apply)

Umbrella PolicyLong-Term Care InsuranceDeath Benefit Life InsuranceLife Insurance
CASH FLOW

Please list monthly income from each source.
Pension

Monthly Income
You:
Current?

YesNo
Start Date:

MonthDayYear
Date
Your Spouse:
Current?

YesNo
Start Date:

MonthDayYear
Date
Survivor Options

Monthly Income
You:
Your Spouse:
Social Security

Monthly Income
You:
Current?

YesNo
Start Date:

MonthDayYear
Date
Your Spouse:
Current?

YesNo
Start Date:

MonthDayYear
Date
Wages

Monthly Income
You:
Your Spouse:
Other Income (2nd Job, Farm Income, Rental Income, etc.)

YOU
Source(s):
Total:
Other Income (2nd Job, Farm Income, Rental Income, etc.)

YOUR SPOUSE
Source(s):
Total:
Are these amounts net or gross? (net = after all deductions)

NetGross
How much are your monthly expenses?

Here are some common expenses: mortgage/rent, food, gas, car loan, insurance, utilities, gifts/donations, medical, taxes, etc.
Total:
Is your current cash flow sufficient and comfortable?

YesNo
Do you live off interest your investment dollars earn?

YesNo
Do you anticipate any significant changes in cash flow?

YesNo
Are you planning any major lifestyle changes?

YesNo
Do you foresee any large purchases greater than $5,000 within the next three years?

YesNo
Do you contribute to charity?

YesNo
LIFE EVENTS
In the near future I expect to: (check all that apply)

Buy a homeSell a homeImprove a homeRetireCare for a parentStart or expand a businessPay off debtStart a part-time jobHelp fund education costs for a family memberSell a propertyReceive an inheritancePurchase a propertyOther
ASSETS

Check the accounts you currently hold and list the total amount in the box provided. If you can, please bring the latest statement for your visit.
Bank / Credit Union Accounts:

Bank / Credit Union Accounts
Bank / Credit Union Accounts (Total Amount):
Mutual Funds / Stocks / Bonds:

Mutual Funds / Stocks / Bonds
Mutual Funds / Stocks / Bonds (Total Amount):
Brokerage Accounts:

Brokerage Accounts
Brokerage Accounts (Total Amount):
IRAs / 401(k) / 403(b) / Keoghs / TSAs:

IRAs / 401(k) / 403(b) / Keoghs / TSAs
IRAs / 401(k) / 403(b) / Keoghs / TSAs (Total Amount):
CDs:

CDs
CDs (Total Amount):
Business Interest:

Business Interest
Business Interest (Total Amount):
Annuities:

Annuities
Annuities (Total Amount):
Life Insurance:

Life Insurance
Life Insurance (Total Amount):
Long-Term Care Insurance:

Long-Term Care Insurance
Long-Term Care Insurance (Total Amount):
Promissory Notes / Contract for Deed:

Promissory Notes / Contract for Deed
Promissory Notes / Contract for Deed (Total Amount):
Other Assets

Other Assets
Other Assets (Total Amount):
Property
Property Home Value:
Autos and Personal Property:
Rental/Additional Properties:
Additional Assets
Description:
Balance Owed:
Pay-Off Date:

MonthDayYear
Date
Description:
Balance Owed:
Pay-Off Date:

MonthDayYear
Date
Description:
Balance Owed:
Pay-Off Date

MonthDayYear
Date
ADDITIONAL INFORMATION
If you’re not already retired, when do you want to retire? List age or year.
You:
Your Spouse:
How did you acquire your wealth?
How involved would you like to be with your investments?

LittleSomewhatA Lot
What are you more concerned about?

Growing your assetsProtecting what you already have
CONCERNS
Which of the following are your top three concerns?

Losing too much money in the stock marketPaying too much in taxesConsidering retirement and if I/we can afford toNot having a reliable income plan for retirementGiving away life savings due to a catastrophic illnessOutliving nest eggUncertainty about stock marketStart a part-time jobLeaving a legacy to children and/or grandchildrenNeed direction with 401(k) and/or IRA accountsOther
OBJECTIVES
Which of the following describes your risk tolerance when it comes to retirement assets?

ConservativeModerateAggressive
What are your financial objectives? (check all that apply)

Income NowTax-Deferred GrowthGuarantees ProvidedPass Assets to BeneficiariesGrowth PotentialOther
INTERESTS AND HOBBIES
What are your passions and favorite pastimes?
NOTES
Total Assets
Should be Empty:

Pre-Appointment Form

CONTACT INFORMATION

Name

Spouse Name

FAMILY

Legal Items

CASH FLOW

Pension

Survivor Options

Social Security

Wages

Other Income (2nd Job, Farm Income, Rental Income, etc.)

Other Income (2nd Job, Farm Income, Rental Income, etc.)

LIFE EVENTS

ASSETS

Property

Additional Assets

ADDITIONAL INFORMATION

CONCERNS

OBJECTIVES

INTERESTS AND HOBBIES