Assets Questionnaire

Assets Questionnaire
Please complete the following form as best you can.
Note, all information submitted in this form is highly confidential.

If you have any questions, please feel free
to call: 913-543-3836 or email: contact@wallastreet.com
Name

First NameLast Name
Email
example@example.com
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Residence Purchase Year:
Primary Residence Purchase Amount:
Primary Residence Current Value:
Primary Residence Tax Basis:
Primary Residence Owner:
(Client, Spouse, Joint, Trust, etc.)
Secondary Property

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Property Purchase Year:
Secondary Property Purchase Amount:
Secondary Property Current Value:
Secondary Property Tax Basis:
Secondary Property Owner:
(Client, Spouse, Joint, Trust, etc.)
Assets: Personal Property
Property #1 Asset Name:
Property #1 Current Value:
Property #1 Tax Basis:
Property #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Property #2 Asset Name:
Property #2 Current Value:
Property #2 Tax Basis:
Property #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Personal Property Additional Notes:
Assets: Taxable Investments
Statement Information

In addition to the information listed below, please provide statements for all investment accounts. You may fax, email or send via postal mail.
Taxable Investment #1 Institution Name:
Taxable Investment #1 Total Value:
Taxable Investment #1 Tax Basis:
Taxable Investment #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Taxable Investment #2 Institution Name:
Taxable Investment #2 Total Value:
Taxable Investment #2 Tax Basis:
Taxable Investment #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Assets: Cash Equivalents
Taxable Investment Additional Notes:
Cash Equivalent #1 Institution Name:
Cash Equivalent #1 Asset Type:

CashCDsT-BillsCheckingSavingsMoney MarketCash Management Account
Cash Equivalent #1 Total Value:
Cash Equivalent #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Cash Equivalent #2 Institution Name:
Cash Equivalent #2 Asset Type:

CashCDsT-BillsCheckingSavingsMoney MarketCash Management Account
Cash Equivalent #2 Total Value:
Cash Equivalent #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Cash Equivalent #3 Institution Name:
Cash Equivalent #3 Asset Type:

CashCDsT-BillsCheckingSavingsMoney MarketCash Management Account
Cash Equivalent #3 Total Value:
Cash Equivalent #3 Owner:
(Client, Spouse, Joint, Trust, etc.)
Cash Equivalent #4 Institution Name:
Cash Equivalent #4 Asset Type:

CashCDsT-BillsCheckingSavingsMoney MarketCash Management Account
Cash Equivalent #4 Total Value:
Cash Equivalent #4 Owner:
(Client, Spouse, Joint, Trust, etc.)
Assets: Retirement Accounts
Retirement Account #1 Institution Name:
Retirement Account #1 Type:
(401(k), IRA, Money Purchase, Profit Sharing, 403(b), Pension, SEP, etc.)
Retirement Account #1 Total Value:
Retirement Account #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Retirement Account #1 Primary Beneficiary:
Retirement Account #2 Institution Name:
Retirement Account #2 Type:
(401(k), IRA, Money Purchase, Profit Sharing, 403(b), Pension, SEP, etc.)
Retirement Account #2 Total Value:
Retirement Account #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Retirement Account #2 Primary Beneficiary:
Retirement Account #3 Institution Name:
Retirement Account #3 Type:
(401(k), IRA, Money Purchase, Profit Sharing, 403(b), Pension, SEP, etc.)
Retirement Account #3 Total Value:
Retirement Account #3 Owner:
(Client, Spouse, Joint, Trust, etc.)
Retirement Account #3 Primary Beneficiary:
Retirement Account #4 Institution Name:
Retirement Account #4 Type:
(401(k), IRA, Money Purchase, Profit Sharing, 403(b), Pension, SEP, etc.)
Retirement Account #4 Total Value:
Retirement Account #4 Owner:
(Client, Spouse, Joint, Trust, etc.)
Retirement Account #4 Primary Beneficiary:
Assets: Retirement Acct. Contributions
Client Annual IRA Contributions:
Spouse Annual IRA Contributions:
Client 401(k) / 403(b) Contributions Percent of Salary:
Client 401(k) / 403(b) Contributions Fixed Amount:
Client Employer Contributions Type:

NonePercent of SalaryMatch PercentFixed AmountMaximum
Client Employer Contributions Percent Match:
Client Employer Contributions Fixed Amount:
Client Post-Tax Contributions Type:

NonePercent of SalaryFixed Amount
Client Post-Tax Contributions Percent of Salary:
Client Post-Tax Contributions Fixed Amount:
Spouse 401(k) / 403(b) Contributions Percent of Salary:
Spouse Employer Contributions Type:

NonePercent of SalaryMatch PercentFixed AmountMaximum
Spouse 401(k) / 403(b) Contributions Percent Match:
Spouse Employer Contributions Fixed Amount:
Spouse Post-Tax Contributions Type:

NonePercent of SalaryFixed Amount
Spouse Employer Contributions Fixed Amount:
Spouse Post-Tax Contributions Percent of Salary:
Assets: Roth IRAs
Spouse Post-Tax Contributions Fixed Amount:
Roth IRA #1 Institution Name:
Roth IRA #1 Total Value:
Roth IRA #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Roth IRA #1 Beneficiary:
Roth IRA #2 Institution Name:
Roth IRA #2 Total Value:
Roth IRA #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Roth IRA #2 Beneficiary:
Assets: 529 Plans
529 Plan #1 Institution Name:
529 Plan #1 Total Value:
529 Plan #1 Grantor:
(Client, Spouse, Joint, Trust, etc.)
529 Plan #1 Beneficiary:
529 Plan #2 Institution Name:
529 Plan #2 Total Value:
529 Plan #2 Grantor:
(Client, Spouse, Joint, Trust, etc.)
529 Plan #2 Beneficiary:
529 Plan #3 Institution Name:
529 Plan #3 Total Value:
529 Plan #3 Grantor:
(Client, Spouse, Joint, Trust, etc.)
529 Plan #3 Beneficiary:
Assets: Stock Options
Stock Option #1 Institution Name:
Stock Option #1 Ticker Symbol:
Stock Option #1 Description:
Stock Option #1 Current Price:
Stock Option #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Stock Option #1 Strategy - Exercise Plan:

As soon as possibleClient's retirementAs late as possibleWhen spouse is a specific ageCalendar YearWhen client is a specific ageSpouse's retirement
Stock Option #1 Strategy - Sell Plan:

As soon as possibleClient's retirementHold a specific number of yearsWhen spouse is a specific ageNeverWhen client is a specific ageCalendar Year
Stock Option #2 Institution Name:
Stock Option #2 Ticker Symbol:
Stock Option #2 Description:
Stock Option #2 Current Price:
Stock Option #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Stock Option #2 Strategy - Exercise Plan:

As soon as possibleClient's retirementAs late as possibleWhen spouse is a specific ageCalendar YearWhen client is a specific ageSpouse's retirement
Stock Option #2 Strategy - Sell Plan:

As soon as possibleClient's retirementHold a specific number of yearsWhen spouse is a specific ageNeverWhen client is a specific ageCalendar Year
Assets: Stock Grants
Stock Grant #1 Number:
Stock Grant #1 Date:

MonthDayYear
Stock Grant #1 Type:

NQISODQRestrictedRestricted 83(b)
Stock Grant #1 Shares Granted:
Stock Grant #1 Exercise Price:
Stock Grant #1 Exercise Price Discount:
Stock Grant #1 FMV at Purchase:
Stock Grant #1 First Vest Date:

MonthDayYear
Stock Grant #1 Vesting Frequency:

MonthlyQuarterlySemi-AnnuallyAnnually
Stock Grant #1 Vesting Periods:
Stock Grant #1 Expiration Date:

MonthDayYear
Stock Grant #1 Shares Sold:
Stock Grant #1 Strategy - Exercise Plan:

As soon as possibleAs late as possibleCalendar YearWhen client is a specific ageClient's retirementWhen spouse is a specific ageSpouse's retirement
Stock Grant #1 Strategy - Sell Plan:

As soon as possibleNeverHold a specific number of yearsCalendar YearWhen client is a specific ageClient's retirementWhen spouse is a specific ageSpouse's retirement
Stock Grant #2 Number:
Stock Grant #2 Date:

MonthDayYear
Stock Grant #2 Type:

NQISODQRestrictedRestricted 83(b)
Stock Grant #2 Shares Granted:
Stock Grant #2 Exercise Price:
Stock Grant #2 Exercise Price Discount:
Stock Grant #2 FMV at Purchase:
Stock Grant #2 First Vest Date:

MonthDayYear
Stock Grant #2 Vesting Frequency:

MonthlyQuarterlySemi-AnnuallyAnnuallyOther
Stock Grant #2 Vesting Periods:
Stock Grant #2 Expiration Date:

MonthDayYear
Stock Grant #2 Shares Sold:
Stock Grant #2 Strategy - Exercise Plan:

As soon as possibleAs late as possibleCalendar YearWhen client is a specific ageClient's retirementWhen spouse is a specific ageSpouse's retirement
Stock Grant #2 Strategy - Sell Plan:

As soon as possibleNeverHold a specific number of yearsCalendar YearWhen client is a specific ageClient's retirementWhen spouse is a specific ageSpouse's retirement
Assets: Annuities
Annuity #1 Institution Name:
Annuity #1 Asset Type:

FixedIndexedVariable
Annuity #1 Type of Fund:
(Qualified, NQ, Tax Free, etc.)
Annuity #1 Total Value:
Annuity #1 Tax Basis:
Annuity #1 Owner:
(Client, Spouse, Joint, Trust, etc.)
Annuity #1 Beneficiary:
Annuity #1 Annuitization Begins:
(Never, Retirement, At Death, Calendar Year, etc.)
Annuity #1 Annuitization Type:
(Life, Term Certain, etc.)
Annuity #1 based on the lifetime of:

ClientSpouseJoint Life
Annuity #1 Guaranteed Years of Payout:
Annuity #1 Term (Years):
Annuity #2 Institution Name:
Annuity #2 Asset Type:

FixedIndexedVariable
Annuity #2 Type of Fund:
(Qualified, NQ, Tax Free, etc.)
Annuity #2 Total Value:
Annuity #2 Tax Basis:
Annuity #2 Owner:
(Client, Spouse, Joint, Trust, etc.)
Annuity #2 Beneficiary:
Annuity #2 Annuitization Begins:
(Never, Retirement, At Death, Calendar Year, etc.)
Annuity #2 Annuitization Type:
(Life, Term Certain, etc.)
Annuity #2 based on the lifetime of:

ClientSpouseJoint Life
Annuity #2 Guaranteed Years of Payout:
Annuity #2 Term (Years):
Assets: Deferred Compensation
Deferred Compensation Institution Name:
Deferred Compensation Total Value:
Deferred Compensation Beneficiary:
Deferred Compensation Owner:

ClientSpouse
Contributions Based On:
(All Earned Income, Salary, etc.)
Employee Contributions Type:
Employee Contributions Percent:
Employee Contributions Amount:
Employer Contributions Type:

NonePercent of SalaryMatch PercentFixed Amount
Employer Contributions Percent Match:
Employer Contributions Maximum Percent Match:
Employer Contributions Amount:
Investments Additional Notes:
Assets: Business Interests
Business Name:
Value of the Business:
Business Tax Basis:
Business Owner:
(Client, Spouse, Joint, Trust, etc.)
Business Type:
(Sole Proprietorship, Partnership, S-Corp, C-Corp, LLC, etc.)
Business Income Indexed At:

No GrowthInflationOther
Business Income:
Business Expenses:
Business Expenses Indexed At:

No GrowthInflationOther
Business Distribution Type:

NoneFixed AmountIncome
Business Distribution Amount:
Business Distribution Percent of Income:
Client active in business?:

YesNo
Spouse active in business?:

YesNo
Number of children active in the business:
Relatives active in the business?:

YesNo
Shareholder, Partnership or Operating Agreement?:

YesNo
Does current agreement permit gifting?:

YesNo
Buy / Sell agreement among owners?:

YesNo
Buy / Sell agreement funded with life insurance?:

YesNo
If yes (on previous question), how much coverage?:
Business Interests Additional Notes:
Should be Empty: