CLIENT QUESTIONNAIRE (use additional sheets as necessary)

This form is more extensive and intensive than what you would normally see from other planners. And it's certainly hard to get people to complete it. But if, as a client, you don't know what is going on or where all your assets are (or you won't take the time to figure it out), don't expect much from your planner. Incomplete or inadequate information- or that which is just made up so you can save time- ultimately leads to a lot of problems later on. DO YOUR HOMEWORK!

This is a VERY detailed questionnaire. Not all may have to be filled out due to your own circumstances. You will undoubtedly have some problems with certain areas- so just call if you are a client and I'll try and lead you through it.

(If you print this, you may have to adjust some lines/tables since they don't convert well to HTML format.)

Full Name________________________________________________

Social Security Number________________

Spouse's/Partner's Full Name______________________

Social Security Number ________________

Date and Place of Birth _______________________________________  Age ____

US Citizen_________

If non Citizen, where ______________

Height _____________               Weight __________________

Spouse Date and Place of Birth_________________________________    Age ____

US Citizen_________

If non Citizen, where _________

Height _______________    Weight ________________

Address___________________________________________________

Home Phone_________________________ Business Phone(s) __________

Pager _________________________ Fax___________________________

Email(s) _______________________________

Years Lived Here_______

Previous Address________________________________________________________

Years Lived There ____

Home Telephone Number___________________

Business___________________________________

Occupation and Business____________________________________________________

Address______________________________________________________

Years with Company ____

Prior Company/Occupation__________________________________

Employee # _______________________

Spouse's/Partner's Occupation _________________________________________

Business Address______________________________________________

Spouse Business Telephone Number_________________________________________

Years with Company ____

Prior Company/Occupation__________________________________

Employee # ________________________

Are there second jobs or other organizational volunteer/professional memberships or activities?

Explain_______________________________________________________________________

Date when married or number of years married and where______________________________

Prior Marriages No____ or Date divorce final_________________________________

Special Requirements of decree______________________________________________

Spouse's Prior Marriages No ___ or Date Divorce Final ________________________

Special Requirements of decree_____________________________________________

Parents: Father Alive _____   Health including any chronic conditions _________________ ______________________________________________________________________

If father deceased, from what and at what age? ________________________________

Spouses Father Alive _____   Health including any chronic conditions _________________ ______________________________________________________________________

Do you have an open dialogue with your parents regarding finances, health care, estate planning, etc.

Explain as necessary_______________________________________________________

Do your parents have a will or trust?____________________  Are you aware of the contents? ____

Do your parents have an LTC policy ________

Will you be providing care ___  Financial________  Direct personal care_______________

Deceased ____  Age _______  Due to _________________________________________

Mother Alive _____   Health including any chronic conditions _________________ ______________________________________________________________________

Spouse's/Partner's Parents: Father Alive _____   Health including any chronic conditions ______________________________________________________________________

Deceased ____  Age _______  Due to _________________________________________

Mother Alive _____   Health including any chronic conditions _________________ ______________________________________________________________________

Deceased ____  Age _______  Due to _________________________________________

Do you have an open dialogue with your parents regarding finances, health care, estate planning, etc.

Explain as necessary_______________________________________________________

Do your parents have a will or trust?____________________  Are you aware of the contents? ____

Do your parents have an LTC policy ________

Will you be providing care ___  Financial________  Direct personal care_______________

Children/other dependents

Name__________________________________ Age_____ Dependent Yes___ No___

Address/City & State____________________________ Occupation ______________________

Married _______ Health _______

Name__________________________________ Age_____ Dependent Yes___ No___

Address/City & State____________________________ Occupation ______________________

Married _______ Health _______

Name__________________________________ Age_____ Dependent Yes___ No___

Address/City & State____________________________ Occupation ______________________

Married _______ Health _______

Name__________________________________ Age_____ Dependent Yes___ No___

Address/City & State____________________________ Occupation ______________________

Married _______ Health _______

Any by prior marriage? If yes, give name(s) and ages _____________________________

Any adopted?_____ If yes, give name _______________________________________

Any problems with current children (disabilities, drugs, learning disorders, spendthrifts) ________________________________________________

Can you/do you talk to your children about finances ___________________________

EDUCATION EXPENSES

Name___________   Birth Date______________  Assumed Inflation Rate________

Start Age End Age Annual Education costs in today's dollars
Pre-Secondary
Undergraduate
Graduate
Post-Graduate

Name___________   Birth Date______________  Assumed Inflation Rate________

Start Age End Age Annual Education costs in today's dollars
Pre-Secondary
Undergraduate
Graduate
Post-Graduate

Name___________   Birth Date______________  Assumed Inflation Rate________

Start Age End Age Annual Education costs in today's dollars
Pre-Secondary
Undergraduate
Graduate
Post-Graduate

Grandchildren

Number ___________________ Age_____________________

By which Child(ren)______________________________________________________

Will you provide for education and how much_________________________________

Other Dependents? Are there any other persons that you declare as dependents?

Name___________________________ Relationship _________________________________

Are you Providing Support to Others?

Name _____________________________ Relationship ___________

Health Problems Does any family member or dependent have a health problem?

Yes ___ No___

Is anyone under current care of a physician? Yes ___ No ____

Is anyone on disability? Yes ___ No ___

Explain, providing names, dates, extent of injury or illness__________________________

______________________________________________________________________________

Entitled to veteran's benefits?_____ If so, provide period of service and any specifics issues

(disability, etc. ___________________________________________________________

When do you expect to retire? __________ Spouse/Partner _______________

Highest Level of Education and/or degrees attained Self_________   Spouse_________

Current Advisers (Include Addresses and Telephone Numbers)

Attorney(s) __________________________________________________________

Reason Selected/Specialty ________________________________________________

Stockbroker ___________________________________________________________

Reason Selected/Specialty ________________________________________________

Insurance agent _________________________________________________________

Reason Selected/Specialty ________________________________________________

Banker _______________________________________________________________

Reason Selected/Specialty_________________________________________________

Personal Physician ______________________________________________________

Reason Selected/Specialty____________________________________________

Other ________________________________________________________________

Reason Selected/Specialty_________________________________________________

Has a request for a statement of earnings been filed within the last three years with social security? _____

If so, please provide a copy

CURRENT ANNUAL INCOME
Type Self Spouse
Salary
Bonus
Commissions
Interest (taxable)
Interest (Non taxable)
Dividends (individual securities and mutual funds)
Capital gains/losses Short Term
Capital gains/losses long term
Previous Year loss carryover
1099 Self Employment Income
Real Estate Rentals
Non Qualified Annuities
Pension Plan
401(k), 403(b), 501(c)3, Keogh distributions
IRA distributions
Life Insurance loans
Child Support (taxable?)
Alimony (taxable?)
Social Security
Gifts
Trusts
Disability Income
Other income (partnerships, mortgages, debts owned to you, etc.)
Sale of Assets
Other- describe
Other

Estimated income for each of the next three years _______ ________

Tax Bracket (Federal & State combined) ________ ________

Local & Other Applicable taxes ________ ________

Please have last three years of tax filings available for review

W-4 allowance Federal ___________ State ___________

ASSETS
Type Self Spouse Trusts Joint Tenancy Community Property
Cash
Checking
Savings
CD's
Money Market
Treasury Bills
US Savings Bonds

Securities Owned - Individual Ownership of stocks or bonds (either held directly or in street name. Do not include company stock)
Name of Security Date Purchased Number of Shares Current Value Ownership

Securities Owned- Mutual Funds
Name of Security Date Purchased Number of Shares Current Value Ownership

Company Stock Only (Stock Option Yes___ No___ , Stock Purchase Yes___ No__)

_____________ ____________ __________________ ___________ ________

_____________ ____________ __________________ ___________ ________

Receivables (may have also been included in income)
Type Description Amount Maturity Date Ownership

Employer Retirement Accounts
Type/Description Vested Value Self Spouse Beneficiary
IRA Standard
Roth IRA
401(k)
Keogh
Pension Plan
Profit Sharing
Employee Stock Plan
Standard Annuity
Tax Sheltered Annuity
403(b)
501(c)3

Any prior rollovers? If so, when, how much, to whom____________________________

If teacher, payroll paid 10 mos. ____ 12 mos.______ Certificated ______ Classified ______

PERS/STRS amounts ______________ ________ ________ ____________

Other (deferred comp, stock options, etc.) _______ ________ ____________

401(k) Total ______________ ________ ________ ____________

401(k) company contribution per $1 personal  investment ________ ________

Policy loans ________ ________

Monthly Pension from employer at Retirement Age ________ ________

Monthly Pension from others at Retirement Age ________ ________

(military, government, etc.)

Projected Retirement Age ________ ________

Pension Lump Sum (if available) or indicate no ________ ________

Real Estate: Describe all loans on property (1st, 2nd, Home Equity Lines of Credit), maturity dates, balloon payments and, if possible, the mortgages payment expressed as part principal and interest.
Address Cost Current Value Mortgage When Purchased
Home
Vacation Home
Multi Family
Commercial
Raw Land

Have you ever done a Tax deferred 1035 exchange? If so describe __________________________ _____________________________________________________________________________

Limited Partnerships
Type Cost Current Value When Purchased
Real Estate
Oil and Gas
Equipment Leasing
Other

Other Investments (such as business interests, franchises)

Address _______ _______ ______

Address _______ _______ ______

Personal Property
Type Cost Current Value
Furniture
Jewelry & Furs
Autos, Campers, Trailers
Boats, Aircrafts
Collections
Clothes
Computer System
Stereo TV System
Other

Last appraisal date _________

INSURANCE

Life

Do you smoke? ______ Have you smoked? If so, when did you quit._____________

Is your health, past and present, excellent ______, average_______, fair or poor ________

If not excellent at all times, please explain_________________________

Have you ever been denied coverage? _______ If so, please explain _______

Life Insurance Coverage Personal- Self
Type Face Value Annual Premium Beneficiary Cash Value Loan Surrender Value
Term
Whole
Universal
Variable
Other

Life Insurance Coverage Personal Spouse
Type Face Value Annual Premium Beneficiary Cash Value Loan Surrender Value
Term
Whole
Universal
Variable
Other

Extra Coverage- (Accidental death, term riders, etc.) _________________________________

Life Insurance Coverage by Employer- Self
Type Face Value Annual Premium Beneficiary Cash Value Loan Surrender Value
Term
Whole
Universal
Variable
Other

Life Insurance Coverage by Employer- Spouse
Type Face Value Annual Premium Beneficiary Cash Value Loan Surrender Value
Term
Whole
Universal
Variable
Other

Extra benefits on any of the above policies (waiver of premium, accidental death, term riders, split dollar)

Also, if employer does not pay all premiums, indicate percentage contributed_____________

General Insurance
Type Coverage Personal -Self Personal- Spouse Employer -Self Employer- Spouse
Hospital and Major Medical
Short term disability
Long Term disability
Homeowner's
Umbrella
Personal Contents
Professional Liability
Automobile

Annuities (non employer)
Type $ Invested Current Value Interest Rate Surrender Charge Annual Payment
Fixed
Variable
Combination

Any deferred compensation plans with employer? ____ If so, provide documents

LIABILITIES (Excluding real estate mortgages and Home Equity Loans) Describe any unique characteristics such as balloon payments, variable rates, etc.
Type Amount Owed Monthly Payment Interest Rate Self or Spouse
Bank Loan
Student Loan
Insurance Policy Loan
Personal
Installment Debt
Credit Cards
Broker, Margin Accounts
Church Charity
Alimony, child Support
Auto Loans
Other

Have you recently received a TRW credit rating report? No ___ Yes____

Any Problems with credit history - i.e. judgments _________________________________________________________________________

Have you ever declared bankruptcy? If yes, circumstances and date(s) _______________

___________________________________________________________________________

ESTATE ISSUES: Do you have a current will? No ___ Yes___ Last Review _______

Do you have a living trust? Yes____  No_____ Last Review

Who are the trustees or executors_______________________________________

How were they selected?___________________________________________________

Who selected them?_____________________________________________________

What are their backgrounds_________________________________________________

Is spouse capable of handling money?_____ If not, are co- trustees capable? ______

Are there separate trusts for beneficiaries? If so, provide details_____________________

______________________________________________________________________________

Provide copies of all trust documents

Are you aware that your life insurance will be taxed as part of your estate? ________

Are you aware that joint tenancy and contractual agreements bypass wills and trusts? _____________________________________________________________________

Do any members of your family expect to receive major inheritances? If so, who, how much and when expected______________________________________________________

Are you currently gifting any assets to anyone?___ If so, to who and how much___________

Are you or would you consider a charitable gift? ________ To whom and how much_____

Are you familiar with charitable remainder/lead trusts? ________

I'm sure you could add other areas. Regardless, if you filled out this form as completely as possible, you are an excellent candidate to figure out where you are now so that you can figure out the rest of your life.

MISCELLANEOUS

What do you expect your investments to earn while working? __________

What do you expect your investments to earn while retired? __________

What to you expect will be the rate of inflation while working__________

What to you expect will be the rate of inflation while retired__________

Asset Allocation                            Pre Retirement          Post Retirement

Large Cap Stocks                          _________%              _________%

Small Cap and Foreign Stocks         _________              _________

U.S. Corporate bonds                    _________              _________

Municipal bonds                              _________              _________

Cash                                               _________              _________

Expected Return                              _________              _________

Optimistic Return                             _________              _________

Pessimistic Return                           _________              _________