Use the items contained on this questionnaire to help identify information
that you feel is important from your client. The form includes extensive
information, identify which items you think are relevant to your scenario.
The objective is not to have your client complete the entire form, the
challenge lies in your ability to obtain only the relevant information.
Because as you know in reality, you will not be able to have a client
provide you with all this information. The challenge further lies in the
limited time frame available for the team to come up with a portfolio,
again reality hits, because as you know clients want to hear back from
you by the next morning.
(If
you print this, you may have to adjust some lines/tables since they don't
convert well to HTML format.)
GENERAL
CLIENT INFORMATION
Provide
Your Name:
Scenario #:
Social
Security Number
Spouse's/Partner's Full Name
Social Security Number
Date and Place of Birth
US Citizen
If non Citizen, where
Spouse Date and Place of Birth
US Citizen
If non Citizen, where
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
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
Date divorce final
Special Requirements of decree
Spouse's Prior Marriages
Date Divorce Final
Special Requirements of decree
Parents:
Father Alive
Health including any chronic conditions
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
Mother, Health including any chronic conditions
Spouse's/Partner's Parents
Father Alive
Health including any chronic conditions
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
Mother Alive _____ Health including any chronic conditions
Children:
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?
Any problems (disabilities, drugs, learning disorders, spendthrifts)
Can you/do you talk to your children about finances
EDUCATION EXPENSES
Name
Birth Date
Assumed Inflation Rate
Pre-Secondary
Undergraduate
Graduate
Post-Graduate
Name
Birth Date
Assumed Inflation Rate
Pre-Secondary
Undergraduate
Graduate
Post-Graduate
CURRENT
ANNUAL INCOME
For Self and Spouse, on an annual basis:
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
ASSETS
For
Self and Spouse Trusts Joint Tenancy Community Property:
Cash
Checking
Savings
CD's
Money Market
Treasury Bills
US Savings Bonds
Securities Owned
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
Stock Options
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
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
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)
Personal Property
Type Cost Current Value
Furniture
Jewelry & Furs
Autos
Campers
Trailers
Boats
Aircrafts
Collections
Clothes
Computer System
Stereo TV System
Other
INSURANCE
Life
Do you smoke?
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 Spouse:
Term
Whole
Universal
Variable
Other
LIABILITIES
Self
and 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 ever declared bankruptcy?
ESTATE ISSUES
Do you have a current will?
Do you have a living trust?
Who are the trustees or executors
How were they selected?
Who selected them?
What are their backgrounds
Is spouse capable of handling money?
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 bypass wills and trusts?
Are you currently gifting any assets to anyone?
Are you or would you consider a charitable gift?
Are you familiar with charitable remainder/lead trusts?
MISCELLANEOUS
What
do you expect your investments to earn while working?
W hat
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
NET
WORTH
Your
net worth is your assets minus your liabilities and is a key element to
your financial plan. However, as stated repeatedly, it is the budget that
controls your life more so than your net worth. Having a whole mess of
money but with no comprehension of how long it will last invariably leads
to financial problems later on. Unfortunately, it may be when you are
70 or 80 years of age when you run out of money and then it is almost
always too late to do much about it.
ASSETS
LIABILITIES
CASH EQUIVALENTS
Charge accounts
Savings Account
Credit Card
Checking account
Personal loan
Money market bank account
Student/tuition loans
Certificates of deposit
Credit Union account
Home Equity Loan
US Treasury Instruments
Savings Bonds
Cash Value of Life Insurance Alimony
Child support
Credit lines
CURRENT
BUDGET
Expense
Item (annualized)
Groceries
Computer
Alcohol/Tobacco Upgrades
Restaurants Software
Personal Repairs
Work Related Supplies
Appliances and Cookware/Kitchen On line Services
Miscellaneous
Entertainment
and Recreation
Vacations
Travel
Religious and Charities
Sporting Events Christmas gifts
Movies/Theater Personal
Parties hosted in home
Fitness Club
Cable TV Daycare
CD's/Tapes Cleaning
Country Club Medical care
Other Hobbies Baby-sitting
Transportation
Car payments
Auto maintenance
Auto insurance
Parking Hair care
Parking Tickets Toiletries
Parking permits Personal care appliances
Public transportation Pocket money allowances
Carpool costs Massages
Taxes and fees
Tolls
Gas
Education
Oil
Education/training expenses
Registration Newspapers
Books/Book clubs
CLOTHING Magazines
Mending/repair Professional dues
Dry cleaning/laundry Personal tuition
New purchases/personal Personal room and board
New purchases/work Child tuition and room and board (current)
Child tuition and room and board (future)
Miscellaneous
Obligations
and Savings
Income
Tax Personal Savings
Medicare Retirement savings
Social Security Company stock/options
Consulting fees 401(k)
Tax preparation TSA's 403(b)/501)c)3
Other tax IRA's
Life insurance Keogh
Term SEP
Whole life SIMPLE
Universal life Investments
Variable Individual securities
Disability insurance Mutual Funds
Umbrella insurance Real estate
Credit card fees Annuities
Credit card payments Fixed
Interest Variable
Principal
Finance fee
Cash advance fee
Alimony/support PETS
Child support Veterinarian
Child care Food
Child allowances Board and care
Business expenses
Attorney fees
Other debt
Union Dues
Storage fees
Postage
Home
Home
mortgage/rent Interest
Hospital
Principal Physician
Home Equity Line Dentist
Maintenance Prescriptions/Vitamins
Furnishings Health Insurance
Gas Medigap insurance
Long term care insurance
Electricity
Telephone
Home
Mobile
Property Insurance
Fire Insurance
Earthquake Insurance Subtotal All Yearly expenses
Flood Insurance Miscellaneous 5% to 10% extra
Umbrella/liability insurance Property
Tax
Condominium/ Association fees
Garbage
Water
Sewer
Well Maintenance
Mowing service
Landscaping service
Septic Tank Cleaning
Snow Removal
Second Home (repeat above)
