Client Questionnaire

Personal Information
Name *

First Name Last Name
Spouse's Name

First Name Last Name
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Date of Birth *
Date of Birth (Spouse)
Employment Information
Current Employer *
Occupation *
Total Annual Income *
Current Employer (Spouse)
Occupation (Spouse)
Total Annual Income (Spouse)
Desired Retirement Age *
Desired Retirement Age (Spouse)
Assets
Type of Account
Approximate Balance
Type of Account
Approximate Balance
Type of Account
Approximate Balance
Type of Account
Approximate Balance
How many years of investment experience do you have? *
Currently receiving a pension?
What is the monthly amount you receive from your pension? If not receiving yet, what is estimated amount?
Currently receiving Social Security?
What is the monthly amount you receive from Social Security? If not receiving yet, what is estimated amount?
Liabilities
Outstanding Mortgage Amount
Current Mortgage Rate
Monthly Mortgage Payment Amount
Debt
Approximate Balance
Debt
Approximate Balance
Debt
Approximate Balance
Total Monthly Household Expenses (Not including mortgage payment) *
Life Insurance Coverage
Type
Amount of Coverage
Type
Amount of Coverage
Life and Financial Goals
Please describe the advice you are looking to receive.
Please select appropriate goals that will be discussed:

Retirement Healthcare Travel New Car New Home Leave Bequest Wedding Private High School Funding College Funding Gift or Donation Home Improvement Other Major Purchase Other
Should be Empty:

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