Confidential Questionnaire Step 1 of 12 8% Welcome to Tier 1 Capital!Thank you for your cooperation and for completing our Confidential Questionnaire and Debt Summary Worksheet. The information you provide will allow us to gain a comprehensive understanding of your financial situation and tailor our advice to your specific needs. We look forward to partnering with you to achieve financial freedom and success.Quick Tips for Completing Your Forms1. Complete the First Page: The first page of the Confidential Questionnaire must be completed to proceed with the process. This information is essential for us to begin our evaluation. 2. Fill Out Applicable Sections: After completing the first page, fill out the sections that apply to your situation. Be thorough and honest to ensure we can provide the most accurate advice. 3. Save Your Progress: You can save your progress and return to the form later without losing any information. This allows you to complete the form at your own pace.Personal and Family InformationYour Name(Required) First Last Your Date of Birth(Required) MM slash DD slash YYYY Contact Number(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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 ChargesExtra PaymentAre you paying any amount over the minimum due each month? Interest 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 ChargesExtra PaymentAre you paying any amount over the minimum due each month? Interest 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 ChargesExtra PaymentAre you paying any amount over the minimum due each month? Interest 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 ChargesExtra PaymentAre you paying any amount over the minimum due each month? Interest 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. Debt Summary WorksheetList of DebtsPlease list all of your current debts, including but not limited to personal credit cards, mortgages, student loans, business loans, car loans, and any other liabilities. You can add additional rows for each item as needed.Description of DebtOwnerAPR (%)Current BalanceCurrent Monthly PaymentMinimum Monthly PaymentAdditional Charges Made Monthly Add Remove
