QUESTIONAIRE

Please take a couple of minutes to complete this questionnaire.  This will help determine how we may best be able to help you. 
All information is completely confidential.


Name:
Gender:
Male   Female  
Date of Birth:
Any Dependents:
Yes   No  
If yes, number and ages:
Marital Status:
Single   Married   Divorced   Widowed  
Spouse's Name
Spouse's Date of Birth
Employment Status:
Employed   Self-Employed   Retired   Unemployed   Homemaker  
Spouse's Employment Status:
Employed   Self-Employed   Retired   Unemployed   Homemaker  

Current Value of Residence(s):
Non-Income Property (car, boat etc.):
Other Personal Assets (jewelry, collectibles etc.):
Investments (Stocks, Bonds, Mutual Funds etc.):
Restricted Stock/Options/Other:
Checking, Savings, CD's:
401k, other Employee Related Savings Plans:
Life Insurance Protection:
Long Term Care Insurance:
Mortgages:
Personal Use (car loans, lines of credit):
Other Debt:
Total Current Household Gross Income:
Forms of Income available to you during retirement:
Social Security   Pension   Investment   Real Estate   Other  
Current Monthly Expenses:
I have an updated will (within past 5 years):
Yes   No  

If the total value of my investments increased by 30% in one year, I would consider the following:
Sell all
Sell a portion of the account
Hold all
Buy more
If the total value of my investments fell by 30% in one year, I would consider the following:
Sell all
Sell a portion of the account
Hold all
Buy more
I invest because...(check all that apply)
I want to preserve my existing capital.
I have current retirement income and I would like to increase or preserve it.
I have a significant financial goal to meet, like a new home, child's education, etc.
I want to accumulate a nest egg for retirement or grow my long term wealth.
I would like to leave a legacy for future generations or make charitable donations.
My comfort level with investing is as follows:
I feel confident in my investing ability, I just would like someone to bounce ideas/thoughts off of from time to time.
I feel pretty good about investing but I know I am not an expert.
I have some general knowledge but want to work with a professional.
I have little knowledge with investing but I want to learn.
I have no interest in making investment decisions.
A loved one used to take care of the investments but now he/she is no longer able or available.
Help!

Questions or Comments:
Phone number
Email
Preferred Contact Method
Phone
Email
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No offers may be made or accepted from any resident outside these states due to various state regulations and registration requirements regarding investment products and services.

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