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Basic Information

Primary

First Name*

Middle Name

Last Name*

Nick Name

Age

Date of Birth

Birth Place

#SS

Gender

Occupation (Last if retired)

Job Title

Years

Employer

City/ State

Retirement date (or desired)

Veteran Information

Branch

Dates Served

War Time Yes No

Secondary

Firstname

Middle Name

Lastname

Nick Name

Age

Date of Birth

Birth Place

#SS

Gender

Occupation (Last if retired)

Job Title

Years

Employer

City/ State

Retirement date (or desired)

Veteran Information

Branch

Dates Served

War Time Yes No

Contact Information

Add Phone Number

Home	Primary Cell Phone	Secondary Cell Phone

Address

City

State

Zip

Primary Email

Secondary Email

Marital Status

Anniversary Date

Family Information

Name	Relationship

Income (monthly)

Primary

Secondary

Social Security

Pension

Wages

Other (investment w/d)

Other

Total

____________________

Total

_______________

Income needed at Retirement or needed if Retired $

Expenses (monthly)

Fixed

Variable

Assets (not held at with our firm)

Add Asset

Value	Tax Status	Company	Type of Inv.	Owner	Contract #

Checking & Savings

Total CD’s

Total Savings & Checking

Real Estate

Add Real Estate

Real Estate	Value	Rental Income	Mortgage	Mortgage Monthly Payment

Debt & Liabilities

Credit Card

Other

Equity Line

Other

Children & Grandchildren

Children

How many children do you have?

Ages

Special Needs Concerns

Yes No

Grandchildren

How many grandchildren do you have?

Ages

Special Needs Concerns

Yes No

Estate Planning

Primary: (Parents longevity)

Mom Living

Yes No

Dad Living

Yes No

Veteran

Yes No

Veteran

Yes No

Secondary: (Parents longevity)

Mom Living

Yes No

Dad Living

Yes No

Veteran

Yes No

Veteran

Yes No

Primary Estate Information

Do you have updated/adequate wills?

Yes No

Have you established any trusts?

Yes No

Uncertain

Will you be receiving a significant inheritance?

Yes No

Uncertain

Do you have long-term health care coverage?

Yes No

Uncertain

Financial Power of Attorney?

Yes No

Uncertain

Healthcare Power of Attorney?

Yes No

Uncertain

Do you have a Living Will?

Yes No

Uncertain

Executor / Executrix other than spouse?

Yes No

Uncertain

Secondary Estate Information

Do you have updated/adequate wills?

Yes No

Have you established any trusts?

Yes No

Uncertain

Will you be receiving a significant inheritance?

Yes No

Uncertain

Do you have long-term health care coverage?

Yes No

Uncertain

Financial Power of Attorney?

Yes No

Uncertain

Healthcare Power of Attorney?

Yes No

Uncertain

Do you have a Living Will?

Yes No

Uncertain

Executor / Executrix other than spouse?

Yes No

Uncertain

Life Insurance & Long Term Care

Primary

Add Primary

Company	Coverage type	Amount

Secondary

Add Secondary

Company	Coverage type	Amount

Medical

Primary

Do you have any current health problems?

Yes No

Have you had any recent health changes?

Yes No

Secondary

Do you have any current health problems?

Yes No

Have you had any recent health changes?

Yes No

Protection

Do you have medical coverage?

Yes No Uncertain

Plan Type (ie HMO, Plan G)

Company?

Do you have disability coverage?

Yes No Uncertain

Do you have personal liability coverage

Yes No Uncertain

Amount?

Questions

Please list any questions you might have

How would you improve your financial situation if you could? Why?

Financial Priorities (only number YOUR Priorities, starting with #1)

Primary

Secondary

Retirement Planning

Saving for College

Saving for Major Purchases

Managing a Budget

Investment Management

Minimizing Taxes

Suitable Insurance Coverage

Provide a Legacy

Caring for Parents

Contributing to a Charity

Other

Investor Experience & History

How much investment experience do you have (in years)?

Stocks

Bonds

Mutual Funds

Annuities

Options

REIT’s

Investment Goals	Low Priority				High Priority
Return should exceed inflation rate	1	2	3	4	5
Principal should be safe	1	2	3	4	5
Investments should be liquid(immediately accessible)	1	2	3	4	5
Diversification is important	1	2	3	4	5
I want to reduce my taxable income	1	2	3	4	5
I want to build tax-free income	1	2	3	4	5
I am interested in long-term growth	1	2	3	4	5
I am interested in short-term profits	1	2	3	4	5

I expect to start drawing income from my investments

Not for at least 20 years

Not now, but within 5 years

In 10 to 20 years

Immediately

In 5 to 10 years

Goals

What are your major objectives for your investments?

Current and future income

Keeping ahead of inflation

Preserving capital

Increasing returns

Building wealth for heirs

General

Are you anticipating any major lifestyle changes?

Yes No Uncertain

(ie., marriage, divorce, retirement, moving, etc.)

If so, what changes are you expecting?

Are you comfortable with your current cash flow?

Yes No Uncertain

Do you anticipate any changes in your cash flow?

Yes No Uncertain

Do you anticipate any major upcoming expenditures?

Yes No Uncertain

If so, what expenditures are you expecting?

Beneficiary Information

Check here if Primary Beneficiary is surviving spouse on all accounts.

Name

Date of Birth

Relationship

SS #

Address

Phone

Primary Contingent

Per stirpes Per capita

Name

Date of Birth

Relationship

SS #

Address

Phone

Primary Contingent

Per stirpes Per capita

Name

Date of Birth

Relationship

SS #

Address

Phone

Primary Contingent

Per stirpes Per capita

Name

Date of Birth

Relationship

SS #

Address

Phone

Primary Contingent

Per stirpes Per capita

Name

Date of Birth

Relationship

SS #

Address

Phone

Primary Contingent

Per stirpes Per capita

Legal

Executor / Executrix

Phone

Contingent

Phone

Power of Attorney

Phone

Primary(Check only if on file)

Power of Attorney

Last Will & Testament

DD214

Secondary(Check only if on file)

Power of Attorney

Last Will & Testament

DD214

Joint

Trust

Tax Return

Add Client

Basic Information

Primary

Occupation (Last if retired)

Veteran Information

Secondary

Occupation (Last if retired)

Veteran Information

Contact Information

Family Information

Income (monthly)

Primary

Secondary

Income needed at Retirement or needed if Retired $

Expenses (monthly)

Assets (not held at with our firm)

Checking & Savings

Real Estate

Debt & Liabilities

Children & Grandchildren

Children

Grandchildren

Estate Planning

Primary: (Parents longevity)

Secondary: (Parents longevity)

Primary Estate Information

Secondary Estate Information

Life Insurance & Long Term Care

Primary

Secondary

Medical

Primary

Secondary

Protection

Questions

Financial Priorities (only number YOUR Priorities, starting with #1)

Primary

Secondary

Investor Experience & History

Goals

General

Beneficiary Information

Legal

Primary(Check only if on file)

Secondary(Check only if on file)

Joint

Next Steps / Other Notes

Goals / Objectives / Info / MTAG to do’s

Next Action Steps (done by client/prospect)