Income & Expenses 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

Client annual salary/bonus amount:

At what rate do you expect your salary/bonus to increase?

No growthLess than inflationEqual to inflationMore than inflation

Are you (client) self-employed?

YesNo

Client annual salary/bonus starts:

(Existing, Calendar Year, etc.)

Client annual salary/bonus ends:

(Calendar Year, Client or Spouse Retirement, Client or Spouse Death, etc.)

Spouse annual salary/bonus amount:

Is your spouse self-employed?:

YesNo

Spouse annual salary/bonus starts:

(Existing, Calendar Year, etc.)

Spouse annual salary/bonus ends:

(Calendar Year, Client or Spouse Retirement, Client or Spouse Death, etc.)

Income: Social Security

The following information is available on your annual social security statement.

Client Retirement: At age 62, your payment would be about:

Client Retirement: What is your full retirement age?:

Client Retirement: At your full retirement age, your payment would be about:

Client Disability: If you became disabled right now, your payment would be about:

Client Survivors: Qualifying benefit amount for your child:

Spouse Retirement: At age 62, your payment would be about:

Spouse Retirement: What is your full retirement age?:

Spouse Retirement: At your full retirement age, your payment would be about:

Spouse Disability: If you became disabled right now, your payment would be about:

Spouse Survivors: Qualifying benefit amount for your child:

Income: Deferred Income

Deferred Income Name:

Deferred Income Type:

(Pension, Deferred Comp, Other Deferred,etc.)

Deferred Income Annual Amount:

Deferred Income Owner:

(Client, Spouse, Joint, Trust, etc.)

Deferred Income starts?:

(Client or Spouse Retirement, Calendar Year, etc.)

Deferred Income ends?:

(Calendar Year, Client or Spouse Retirement, Client or Spouse Death, etc.)

Income: Other Income

Other Income Name:

Other Income Type:

(Business Distribution, Partnership Distribution, Real Estate, Trust, Annuity, Other)

Other Income Tax Treatment:

(Earned Income, Capital Gains, Qualified Dividends, Investment Ordinary Income, Non-Taxable)

Other Income Annual Amount:

Other Income Owner:

(Client, Spouse, Joint, Trusts, etc.)

Other Income guaranteed?:

YesNo

Other Income starts?:

(Client or Spouse Retirement, Calendar Year, etc.)

Income: Miscellaneous

Is your joint (client and spouse) net worth (excluding primary residence) in excess of $1,000,000?

YesNo

Did you (client) have an individual income in excess of $200,000 in each of the past two years? Choose "No" if you do NOT expect an excess of $200,000 this year as well.

YesNo

Did you (client and spouse) have a joint income in excess of $300,000 in each of the past two years? Choose "No" if you do NOT expect an excess of $300,000 this year as well.

YesNo

Income Additional Notes:

Expenses: Living Expenses

Estimated current annual living expenses:

Estimated retirement annual living expenses:

Client's living expense in event of...

Spouse's death before retirement:

Spouse's death in retirement:

Spouse's living expense in event of.....

Client's death before retirement:

Client's death in retirement:

At what rate are the living expenses listed above expected to grow?

(No Growth, Inflation, etc.)

Expenses: Education

Child #1 Full Name:

Child #1 Estimated Annual Education Amount:

Child #1 Example School (if not sure of annual amount):

Child #1 Education Expense Indexed at:

(No Growth, Inflation, Other)

Child #1 Starting Year:

Child #1 Ending Year:

Child #2 Full Name:

Child #2 Estimated Annual Education Amount:

Child #2 Example School (if not sure of annual amount):

Child #2 Education Expense Indexed at:

(No Growth, Inflation, Other)

Child #2 Starting Year:

Child #2 Ending Year:

Child #3 Full Name:

Child #3 Estimated Annual Education Amount:

Child #3 Example School (if not sure of annual amount):

Child #3 Education Expense Indexed at:

(No Growth, Inflation, Other)

Child #3 Starting Year:

Child #3 Ending Year:

Expenses: Other

Expense #1 Name:

Expense #1 Type:

(Wedding, Automobile, Vacation property, etc.)

Expense #1 Annual Amount:

Expense #1 Indexed at:

(No Growth, Inflation, Other)

Expense #1 Starting Year:

Expense #1 Ending Year:

Expense #1 Name:

Expense #2 Type:

(Wedding, Automobile, Vacation property, etc.)

Expense #2 Annual Amount:

Expense #2 Indexed at:

(No Growth, Inflation, Other)

Expense #2 Starting Year:

Expense #2 Ending Year:

Expense Additional Notes: