Client Questionnaire

Personal Information
Name*

First NameLast Name
Spouse's Name

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone 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:

RetirementHealthcareTravelNew CarNew HomeLeave BequestWeddingPrivate High School FundingCollege FundingGift or DonationHome ImprovementOther Major PurchaseOther
Should be Empty: