Confidential Questionnaire Step 1 of 11 9% Personal and Family InformationYour Name(Required) First Last Your Date of Birth(Required) MM slash DD slash YYYY Contact Number(Required)Email(Required) Spouse's Name First Last Spouse's Date of Birth MM slash DD slash YYYY Child 1 Name First Last Child 1 Date of Birth MM slash DD slash YYYY Child 2 Name First Last Child 2 Date of Birth MM slash DD slash YYYY Child 3 Name First Last Child 3 Date of Birth MM slash DD slash YYYY Child 4 Name First Last Child 4 Date of Birth MM slash DD slash YYYY Income (Occupation, Income, and Income Tax Rates)What do you do for work? (Position) Where do you work?Occupation/Employer Name Your Current Base SalaryYour Annual Increase (%)Your Annual BonusWhat does your spouse do for work? (Position - if applicable) Where does your spouse work?Occupation/Employer Name Spouse's Current Base SalarySpouse's Annual Increase (%)Spouse's Annual BonusIncome Tax Rate (%)What is your current effective tax rate?Inflation Rate (%)What Assumption should we use?Retirement Tax Rate (%)What tax bracket do you think you'll be in during retirement?Approximate Credit ScorePlease enter a number from 300 to 850. Next, Please input information on your current financial position so we can get a better idea of your current financial positionWe'll start with: Retirement Assets (Social Security, PERs, Railroad Pension, etc.)1.Benefit ProviderTell us what type of account this is or where the assets are being held. Social Security, PERs, Railroad Pension, etc. Owner's name(Hint: you or your spouse) Annual BenefitWhat amount of income do you expect from this source in retirement?COLA (%)Does this account have a cost of living adjustment?Percent Taxable (%)What percent of the benefit will be subject to taxes?Benefit Start AgeWhen do you expect to start collecting these benefits?Benefit End AgeWill these benefits end? If so, at what age?2. Benefit ProviderTell us what type of account this is or where the assets are being held. Social Security, PERs, Railroad Pension, etc. Owner's Name(Hint: you or your spouse) Annual BenefitWhat amount of income do you expect from this source in retirement?COLA (%)Does this account have a cost of living adjustment?Percent Taxable (%)What percent of the benefit will be subject to taxes?Benefit Start AgeWhen do you expect to start collecting these benefits?Benefit End AgeWill these benefits end? If so, at what age?3. BenefitTell us what type of account this is or where the assets are being held. Social Security, PERs, Railroad Pension, etc. Owner's Name(Hint: you or your spouse) Annual BenefitWhat amount of income do you expect from this source in retirement?COLA (%)Does this account have a cost of living adjustment?Percent Taxable (%)What percent of the benefit will be subject to taxes?Benefit Start AgeWhen do you expect to start collecting these benefits?Benefit End AgeWill these benefits end? If so, at what age?4. Benefit ProviderTell us what type of account this is or where the assets are being held. Social Security, PERs, Railroad Pension, etc. Owner's Name(Hint: you or your spouse) Annual BenefitWhat amount of income do you expect from this source in retirement?COLA (%)Does this account have a cost of living adjustment?Percent Taxable (%)What percent of the benefit will be subject to taxes?Benefit Start AgeWhen do you expect to start collecting these benefits?Benefit End AgeWill these benefits end? If so, at what age?5. Benefit ProviderTell us what type of account this is or where the assets are being held. Social Security, PERs, Railroad Pension, etc. Owner's Name(Hint: you or your spouse) Annual BenefitWhat amount of income do you expect from this source in retirement?COLA (%)Does this account have a cost of living adjustment?Percent Taxable (%)What percent of the benefit will be subject to taxes?Benefit Start AgeWhen do you expect to start collecting these benefits?Benefit End AgeWill these benefits end? If so, at what age? Other Future Income or AssetsDo you anticipate any windfalls of assets in the future? - please list any inheritances, business sales or other windfalls you anticipate below...1.Description of Future Income/AssetWhere is the money coming from? (Inheritance, Sale of Business, etc.) Anticipated ValueHow much is the expected value of the upcoming income/assetEvent Age/ YearWhen is the expected date of windfall for this asset?Owner/PayeeWho will receive the money 2.Description of Future Income/AssetWhere is the money coming from? (Inheritance, Sale of Business, etc.) Anticipated ValueHow much is the expected value of the upcoming income/assetEvent Age/ YearWhen is the expected date of windfall for this asset?Owner/PayeeWho will receive the money 3.Description of Future Income/AssetWhere is the money coming from? (Inheritance, Sale of Business, etc.) Anticipated ValueHow much is the expected value of the upcoming income/assetEvent Age/ YearWhen is the expected date of windfall for this asset?Owner/PayeeWho will receive the money Assets (Real Estates and Mortgages)1. Primary Residence Purchase Date MM slash DD slash YYYY Purchase PriceTotal price of this propertyCurrent Market ValueWhat is the current market selling price of this property?DownpaymentHow much is the initial payment made?Loan Origination DateLoan start date MM slash DD slash YYYY Original Loan AmountPrincipal Loan AmountOriginal Loan TermHow many years to pay the loan?Annual Interest Rate (%)Yearly Interest RateLoan Remaining BalanceHow much is left to pay?Monthly PaymentMonthly Principal and Interest Payment2. Second Residence Purchase Date MM slash DD slash YYYY Purchase PriceTotal price of this propertyCurrent Market ValueWhat is the current market selling price of this property?Down PaymentHow much is the initial payment made?Loan Origination DateLoan start date MM slash DD slash YYYY Original Loan AmountPrincipal Loan AmountOriginal Loan TermHow many years to pay the loan?Annual Interest Rate (%)Yearly Interest RateRemaining Loan BalanceHow much is left to pay?Monthly PaymentMonthly Principal and Interest Payment3. Other Real Estate Purchase Date MM slash DD slash YYYY Purchase PriceTotal price of this propertyCurrent Market ValueWhat is the current market selling price of this property?Down PaymentHow much is the initial payment made?Loan Origination DateLoan start date MM slash DD slash YYYY Original Loan AmountPrincipal Loan AmountOriginal Loan TermHow many years to pay the loan?Annual Interest Rate (%)Yearly Interest RateRemaining Loan BalanceHow much is left to pay?Monthly PaymentMonthly Principal and Interest Payment Qualified Retirement Accounts1. Name or Type of Qualified Retirement PlanIs it IRA, Roth, 401k, SEP, deferred comp, pension balances, etc.? Institution Owner Contributions or Withdrawals (year)Employer MatchHow much does your employer contribute to this plan?Account BalanceAnnual Return (%)2. Name or Type of Qualified Retirement PlanIs it IRA, Roth, 401k, SEP, deferred comp, pension balances, etc.? Institution Owner Contributions or Withdrawals (year)Employer MatchHow much does your employer contribute to this plan?Account BalanceAnnual Return (%)3. Name or Type of Qualified Retirement PlanIs it IRA, Roth, 401k, SEP, deferred comp, pension balances, etc.? Institution Owner Contributions or Withdrawals (year)Employer MatchHow much does your employer contribute to this plan?Account BalanceAnnual Return (%)4. Name or Type of Qualified Retirement PlanIs it IRA, Roth, 401k, SEP, deferred comp, pension balances, etc.? Institution Owner Contributions or Withdrawals (year)Employer MatchHow much does your employer contribute to this plan?Account BalanceAnnual Return (%)5. Name or Type of Qualified Retirement PlanIs it IRA, Roth, 401k, SEP, deferred comp, pension balances, etc.? Institution Owner Contributions or Withdrawals (year)Employer MatchHow much does your employer contribute to this plan?Account BalanceAnnual Return (%) Savings and Investment Accounts1. Name or Type of Investment/Savings Account(cd’s, securities, bonds, mutual funds, ETF’s, annuities, etc.) Institution Owner Contributions or Withdrawals (year)Account BalanceCost BasisAmount of your capital investmentAnnual Return (%)2. Name or Type of Investment/Savings Account(cd’s, securities, bonds, mutual funds, ETF’s, annuities, etc.) Institution Owner Contributions or Withdrawals (year)Account BalanceCost BasisAmount of your capital investmentAnnual Return (%)3. Name or Type of Investment/Savings Account(cd’s, securities, bonds, mutual funds, ETF’s, annuities, etc.) Institution Owner Contributions or Withdrawals (year)Account BalanceCost BasisAmount of your capital investmentAnnual Return (%)4. Name or Type of Investment/Savings Account(cd’s, securities, bonds, mutual funds, ETF’s, annuities, etc.) Institution Owner Contributions or Withdrawals (year)Account BalanceCost BasisAmount of your capital investmentAnnual Return (%)5. Name or Type of Investment/Savings Account(cd’s, securities, bonds, mutual funds, ETF’s, annuities, etc.) Institution Owner Contributions or Withdrawals (year)Account BalanceCost BasisAmount of your capital investmentAnnual Return (%) LIABILITIESInstallment Loans1. Type of Loan(Auto, boat, RV, student/parent college, HELOC, etc.) Purpose of Loan Monthly PaymentHow much do you pay monthly?Interest Rate (%)Months RemainingHow many months left to pay for this loan?Unpaid BalanceHow much is the remaining loan amount to pay?2. Type of Loan(Auto, boat, RV, student/parent college, HELOC, etc.) Purpose of Loan Monthly PaymentHow much do you pay monthly?Interest Rate (%)Months RemainingHow many months left to pay for this loan?Unpaid BalanceHow much is the remaining loan amount to pay?3. Type of Loan(Auto, boat, RV, student/parent college, HELOC, etc.) Purpose of Loan Monthly PaymentHow much do you pay monthly?Interest Rate (%)Months RemainingHow many months left to pay for this loan?Unpaid BalanceHow much is the remaining loan amount to pay?4. Type of Loan(Auto, boat, RV, student/parent college, HELOC, etc.) Purpose of Loan Monthly PaymentHow much do you pay monthly?Interest Rate (%)Months RemainingHow many months left to pay for this loan?Unpaid BalanceHow much is the remaining loan amount to pay? Revolving Credit Lines1. Type of Card/Issuer(Credit cards, store charge cards, checking credit lines, etc.) Monthly PaymentHow much do you pay monthly?Monthly New ChargesInterest RateUnpaid BalanceGrace Period on New Charges Yes No 2. Type of Card/Issuer(Credit cards, store charge cards, checking credit lines, etc.) Monthly PaymentHow much do you pay monthly?Monthly New ChargesInterest RateUnpaid BalanceGrace Period on New Charges Yes No 3. Type of Card/Issuer(Credit cards, store charge cards, checking credit lines, etc.) Monthly PaymentHow much do you pay monthly?Monthly New ChargesInterest RateUnpaid BalanceGrace Period on New Charges Yes No 4. Type of Card/Issuer(Credit cards, store charge cards, checking credit lines, etc.) Monthly PaymentHow much do you pay monthly?Monthly New ChargesInterest RateUnpaid BalanceGrace Period on New Charges Yes No Life Insurance (Term, Cash Value)1. Policy TypeWhat type of life insurance policy do have? Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? BeneficiaryWho will receive the death benefit? Annual PremiumHow much do you pay in premiums every year?Outstanding Loan AmountIf you took a loan from your policy, what is the loan amount?Current Cash ValueThe total amount of money inside your policyDeath BenefitHow much will the beneficiary receive incase of death of the insured?Tell us more about the policy.How long is the term? At what age does the premium stops? Any other information you would like to share about the policy?2. Policy TypeWhat type of life insurance policy do have? Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? BeneficiaryWho will receive the death benefit? Annual PremiumHow much do you pay in premiums every year?Outstanding Loan AmountIf you took a loan from your policy, what is the loan amount?Current Cash ValueThe total amount of money inside your policyDeath BenefitHow much will the beneficiary receive incase of death of the insured?Tell us more about the policy.How long is the term? At what age does the premium stops? Any other information you would like to share about the policy?3. Policy TypeWhat type of life insurance policy do have? Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? BeneficiaryWho will receive the death benefit? Annual PremiumHow much do you pay in premiums every year?Outstanding Loan AmountIf you took a loan from your policy, what is the loan amount?Current Cash ValueThe total amount of money inside your policyDeath BenefitHow much will the beneficiary receive incase of death of the insured?Tell us more about the policy.How long is the term? At what age does the premium stops? Any other information you would like to share about the policy?4. Policy TypeWhat type of life insurance policy do have? Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? BeneficiaryWho will receive the death benefit? Annual PremiumHow much do you pay in premiums every year?Outstanding Loan AmountIf you took a loan from your policy, what is the loan amount?Current Cash ValueThe total amount of money inside your policyDeath BenefitHow much will the beneficiary receive incase of death of the insured?Tell us more about the policy.How long is the term? At what age does the premium stops? Any other information you would like to share about the policy? Other Insurance (auto, homeowners, renters, umbrella, health, disability, long term care, etc.)1. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?2. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?3. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?4. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?5. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?6. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?7. Policy Type Insurance Company Purchase DatePolicy effective date MM slash DD slash YYYY Named InsuredWho is insured? Benefit CoverageDoes it includes damage, liability, medical coverage, etc? Please indicate below. Annual PremiumHow much do you pay in premiums every year?DeductibleTell us more about the policy.Any other information you would like to share about the policy?Do you have Wills and/or Living Trust? Yes No Date Last ReviewedWhen was the last time your Will and/or Living Trust was reviewed? MM slash DD slash YYYY Future Expenses (college, weddings, etc.)Do you have any expected expenses coming up?1. Description of Future ExpenseWhat is is this future up coming expenses? Expense AmountYear PayorWho will pay for this expenses? 2. Description of Future ExpenseWhat is is this future up coming expenses? Expense AmountYear PayorWho will pay for this expenses? 3. Description of Future ExpenseWhat is is this future up coming expenses? Expense AmountYear PayorWho will pay for this expenses? Additional Comments:Other factors that could be important to your financial position.
