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Client Questionnaire

Thursday July 27th, 2006 2:21pm EST    
Personal Information
Name:

Occupation:

Birthday:
Select One:
Single    Married    Divorced    Other
Spouse's Name:

Occupation:

Birthday:
Check All That Apply:
Employed    You    Spouse
Self-Employed    You    Spouse
Retired    You    Spouse
Address:

City:

State:

Zip:
Home Phone:

Work Phone:

Email Address:
Spouse's Email Address:
Number of Children:

Ages:

Number of Dependents Living with You:
Names:
Is Anyone Disabled?:
Yes    No
If Yes, Please Explain:
 
Asset Information
Estimate the value of the following:
Liability Information
Please estimate the balances of the following:
Your Home $ Outstanding Installment Loans, Credit Card Balances $
Other Real Estate $ Mortgage(s) on your home $
Checking, Savings/CDs, Money Market Funds $ Mortgage(s) on other Real Estate $
Retirement Accounts (IRAs, 401Ks, SEPs, Keoughs) $ Other Liabilities $
Company Savings & Profit Sharing Plans $   $
Other Assets $   $
TOTAL ASSESTS $ TOTAL LIABILITIES $
 
Income & Expenditure Information
Please estimate the balances of the following:
Annual Household Income $
Is income fairly uniform & predictable? Yes     No
Annual Living Expenditures (Including Federal, State & Local Taxes) $
Annual Savings
(Including company savings plans, personal savings & contributions to retirement plans)
$
 
Income Tax Information

Are all Federal, State & Local tax returns up to date and filed on time?
Yes     No

Are any of your income tax filings on extension?
Yes     No

 
Estate Planning Information
Check the appropriate box:

Do you and your spouse (if applicable) each have a will?
Yes     No

Do your will(s) have trust arrangements?
Yes     No

Do you and your spouse (if applicable) have a living trust?
Yes     No

Do you and your spouse (if applicable) have health proxies?
Yes     No

Do you and your spouse (if applicable) have durable power?
Yes     No

 
Insurance Information

Which policies do you have? (check all that apply)
Homeowners     Disability     Life     Long Term Care     Umbrella

Total death benefit of life insurance:
You $     Spouse $
How many automobiles do you own?
You
 
Your Financial Planning Goals & Investment Objectives
How important are the following financial planning objectives? Rank in order of importance (1 = most important, 3 = least)

Retire comfortably
1     2     3    

Provide for children's education
1     2     3    

Save on income taxes
1     2     3    

Provide for survivors in the event of my death
1     2     3    

Structure my estate to minimize estate taxes
1     2     3    

Other (please explain)
1     2     3     Please Explain:

If retirement is one of your goals, at what age would you like to retire?

Your spouse? (If Applicable)

How important are the following investment objectives? Rank in order of importance (1 = most important, 3 = least)

Increase current income
1     2     3    

Spread risk among investments (i.e. diversity)
1     2     3    

Have cash available for emergencies or investment opportunities (i.e. liquidity)
1     2     3    

Accumulate funds that will keep pace with inflation or do better than inflation
1     2     3    

Use borrowed funds to increase return from my investments (i.e. leverage)
1     2     3    

Minimize the time I have to spend managing my investments
1     2     3

 
What Is Your Attitude Towards Risk?
Check the one that best describes your attitude:

Strongly dislike risk, prefer very safe investments (i.e. insured savings, government securities, etc.)

Prefer little risk. I want to know how much my investment will pay (i.e. highly-rated bonds)

Willing to assume some risk (i.e. stocks, mutual funds, etc.)

Prefer greater risk (i.e. speculative stocks and other investments where the return is uncertain, but may be substantial)

 
Miscellaneous Information

Have you ever been unhappy with the recommendations of a stockbroker, insurance agent and/or any other financial advisor or consultant?
Yes     No
If Yes, Please Explain:

Do you expect any inheritances, legal settlements or gifts that may affect your financial plan?
Yes     No
If Yes, Please Explain:

How were your current investment assets selected? (Who devised where they where going to go and why):

Indicate which of the following statements summarize your attitudes or beliefs using a scale of 1-5.
(1 being most true and 5 least true)

I would rather work longer than reduce my standard of living in retirement.
1     2     3     4     5

I feel that I/we can reduce our current living expenses to save more for the future if needed.
1     2     3     4     5

I am more concerned about protecting my assets than about growth.
1     2     3     4     5

I prefer mutual funds to individual stocks and bonds.
1     2     3     4     5

I am comfortable with investments that promise slow, long term appreciation and growth.
1     2     3     4     5

I don't brood over bad investment decisions I've made.
1     2     3     4     5

I feel comfortable with aggressive growth investments.
1     2     3     4     5

I don't like surprises.
1     2     3     4     5

I am optimistic about my financial future.
1     2     3     4     5

My immediate concern is for income rather than growth opportunities.
1     2     3     4     5

I am a risk taker.
1     2     3     4     5

I make investment decisions comfortably and quickly.
1     2     3     4     5

I like predictability and routine in my daily life.
1     2     3     4     5

I usually pick the tried and true, the slow, safe but sure investments.
1     2     3     4     5

I need to focus my investment efforts on building cash reserves.
1     2     3     4     5

I prefer predictable, steady return on my investments, even if the return is low.
1     2     3     4     5

I am interested in providing for my children's education.
1     2     3     4     5

 
Look this Form over Before Submission
 
   

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