This questionnaire is designed to draw your attention to certain key areas of your financial life that are commonly neglected. It will also give us a better view of your situation so that we can help you look toward the future, and not just report the past. Name*FirstLastAddressStreet AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodePhoneEmail*Name of ReferralHave you previously consulted with a financial planner?YesNoDo you have a will?YesNoWhen was it last reviewed?Do you have a living trust?YesNoDo you have a medical durable power of attorney?YesNoWhen was it last revised?Do you have a living will (this provides others with the right to make medical decisions regarding your life)?YesNoDo you plan to pay for your children's (grandchildren's) college education?YesNoAre you comfortable in your ability to do so?YesNoHow much life insurance do you have?Spouse?Do you have disability coverage?YesNoIs your homeowners policy at replacement value?YesNoDoes your homeowners policy include protection from ordinance changes? (e.g. the city passes an ordinance to earthquake proof your home)YesNoDo you have earthquake insurance?YesNoIf so how much?When do you plan to retire?What is your net worth?How much money do you save per year?Do your expenditures exceed your revenue?YesNoIf so, how much?Life ExpectancyHow old did your mother live?How old did your father live?Is your life expectancy the same?YesNoIs your life expectancy the same?YesNoHusband / Wife's Current Age?Husband / Wife's Date of BirthMMDDYYYYMortgage - Is it fixed or variable?Rate?When will the mortgage be paid in full?How much do you have invested in the following investment categories?Cash, Money Market Funds, T-BillsInsurance Cash Values & AnnuitiesNotes, Mortgages and Accounts ReceivableBonds and Bond FundsStocks and Stock FundsKeoghs, IRAs, 401k, Pension & Profit Sharing PlansPrecious Metals, CollectiblesManaged Real Estate Limited PartnershipsOil & Gas Limited PartnershipsPlease rate your comfort level in the following areas:(relative scale: 0=None 2=Low 5=High 7=Very High)Estate Plan - Comfort with your present arrangements1234567Life Insurance - Comfort with your present coverage1234567Disability - Comfort with your present protection1234567Retirement - Comfort with your present expected income1234567Savings Rate - Satisfaction with your present savings rate1234567Investment Return - Satisfaction with your present investment performance1234567What are your biggest financial concerns?Would you like more information on how we can assist you in financial and investment advisory services?YesNoPhoneThis field is for validation purposes and should be left unchanged.