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 _________ _________
Congratulations!