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Confidential Questionnaire

By Regina Simmons,2014-07-09 20:52
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Confidential Questionnaire ...

    Confidential Questionnaire

Client Name: _____________________ Client (Partner) Name _______________________

     Home Address: _____________________ Home Address: _______________________

    City, State: _____________________ City,State: _______________________

    Zip Code: _____________________ Zip Code: _______________________

    Home Number: _____________________ Home Number: _______________________

    Work Number: _____________________ Work Number: _______________________

    Fax Number: _____________________ Fax Number: _______________________

    Cell Number: _____________________ Cell Number: _______________________

    E-Mail: _____________________ E-Mail: _______________________

    Social Security # _____________________ Social Security #: _______________________

    Birthdate: _____________________ Birthdate: _______________________

    Family Members:

    Name Relationship Date of Birth Dependent Lives with You

    ____________________ _________________ _________ Yes or No Yes or No

    ____________________ _________________ _________ Yes or No Yes or No

    ____________________ _________________ _________ Yes or No Yes or No

    ____________________ _________________ _________ Yes or No Yes or No

    ____________________ _________________ _________ Yes or No Yes or No

    Employment/Career Information

    Employer _____________________ Employer: _______________________

    Title/Job _____________________ Title/Job _______________________

    # of Years _____________________ # of years: _______________________

    Satisfaction Level High Medium Low Satisfaction Level High Medium Low

    Pension: Yes or No Pension: Yes or No

    Other Retirement Plans/Benefits__________________ Other Retirement Plans/Benefits ___________________

    _______________________________________ _________________________________________

    Any loans against Retirement Assets?______________ Any loans against Retirement Assets?___________________ Employment Contracts Yes or No Employment Contracts Yes or No

    Deferred Compensation Agreements Yes or No Deferred Compensation Agreements Yes or No

    Other Benefits _________________________ Other Benefits ____________________________

    I plan to continue in I plan to continue in

    this career for ___________________________ this career for__________________________________

? Copyright Loreine Smith 2003

    What is your goal you would like to achieve What is your goal you would like to achieve with

    With this visit?_______________________ this visit?__________________________________

    ___________________________________ _________________________________________ Number them as to priority with 1 being the highest Number them as to Priority with 1 being the highest. What are your primary goals you would like to What are your primary goals you would like to ____________________________________ _________________________________________ achieve with the guidance of a planner? achieve with the guidance of a planner? ____________________________________ _________________________________________

    ____________________________________ _________________________________________

    ____________________________________ _________________________________________

    ____________________________________ _________________________________________

    ____________________________________ _________________________________________

    ____________________________________ _________________________________________

    ____________________________________ _________________________________________

    Some Suggestions might be: Funding my children’s/grandchildren’s education, begin focusing on retirement income

    sources and lifestyle, Knowing what my financial picture looks like, Having a better idea of how my investments work, Having someone take a look at my investment structure, Estate Planning, Developing a Workable Spending Plan,

    Obtaining a Financial Check up, Saving to Buy a Home, Divorce Planning, etc.

    I plan to retire in(# of years) ___________________ I plan to retire in(# of years) ____________________

    When I retire my lifestyle will ______________ When I retire my lifestyle will _________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    My retirement plans are____________________ My retirement plans are_______________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________

    _______________________________________ __________________________________________ In todays dollars, what is your monthly retirement In todays dollars, what is your monthly retirement income

    Income objective?___________________________ objective?______________________________________

    How did you calculate this?________________ How did you calculate this?____________________

    ? Copyright Loreine Smith 2003

Document Last Updated Document Last Updated

    Wills Yes or No __________ Wills Yes or No __________

    Do you have Estate Planning Documents? Do you have Estate Planning Documents? Living Trusts Yes or No __________ Living Trusts Yes or No __________

    Power of Attorney Yes or No __________ Power of Attorney Yes or No __________

    Living Will Yes or No __________ Living Will Yes or No __________

    Other Trusts Yes or No __________ Other Trusts Yes or No ___________

    Other Documents________________________ Other Documents_________________________

    Do you have Life Insurance?_______________ Do you have Life Insurance?________________

    Do you have Long Term Care Insurance?_____ Do you have Long Term Care Insurance?______

    When was the last time you reviewed your distribution When was the last time you reviewed your distribution

    instructions in the event of your death on bank accounts instructions in the event of your death on bank accounts,

    IRA’s, Annuities, Life Insurance, Retirement plans, IRA’s, Annuities, Life Insurance, Retirement plans,

    brokerage accounts, etc.?_________________________ brokerage accounts,etc.? _______________________

    I know what I spend monthly. Yes or No I know what I spend monthly. Yes or No

    I have a plan in place to guide I have a plan in place to guide

    my spending and saving goals Yes or No my spending and saving goals Yes or No

    I know what I own and how it is I know what I own and how it is

    titled. Yes or No titled. Yes or No

    I am comfortable with my I am comfortable with my current

    current financial choices Yes or No financial choices. Yes or No

    I know what my net worth is. Yes or No I know what my net worth is. Yes or No

    I keep track of my investments Yes or No I keep track of my investments Yes or No

    Why Not?_____________________________ Why Not?__________________________________

    How would you rate your investment knowledge? How would you rate your investment knowledge?

Poor Average Above Average Poor Average Above Average

    Why?_________________________________ Why?_____________________________________

    ______________________________________ __________________________________________

    ? Copyright Loreine Smith 2003

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