Personal Confidential Questionnaire

Personal Information

Primary Client

First Name

Last Name

Date of Birth

Birth State

Cell Phone

Spouse / Partner

First Name

Last Name

Date of Birth

Birth State

Cell Phone

Street Address

Marital Status

Children Information

Provide full names and dates of birth for dependents.

Child 1 Full Name

Child 1 DOB

Child 2 Full Name

Child 2 DOB

Child 3 Full Name

Child 3 DOB

Child 4 Full Name

Child 4 DOB

Employment & Income

Primary Client Income

Occupation

Employer

Annual Base Salary ($)

Annual Commissions/Bonuses ($)

Spouse / Partner Income

Occupation

Employer

Annual Base Salary ($)

Annual Commissions/Bonuses ($)

Assets & Savings

Total Cash/Bank Balances ($)

Total Retirement Accounts (401k, IRA, etc.) ($)

Total Taxable Investments (Brokerage) ($)

Estimated Primary Residence Value ($)

Estimated Business Value (If you own a business) ($)

Liabilities & Debt

Current Mortgage Balance ($)

Other Debt (Auto, Student, Credit Card) ($)

Business Debt / Loans ($)

Protection & Estate

Life Insurance Coverage Total ($)

Disability Insurance Coverage ($/mo)

Health Insurance Plan/Provider

Auto Insurance Liability Limits

Homeowners Insurance Coverage ($)

Umbrella Liability Policy ($)

Do you have a valid, executed will?

Yes

Monthly Cash Flow

Estimate your average monthly household expenses.

Basic Living Expenses

Housing (Rent/Mortgage) ($)

Utilities (Power, Water, Internet) ($)

Groceries & Dining Out ($)

Transportation (Gas, Maintenance) ($)

Insurance Premiums (Monthly)

Life & Health Insurance ($)

Auto & Home Insurance ($)

Lifestyle & Other

Lifestyle & Entertainment ($)

Miscellaneous/Other ($)

Goals & Preferences

What is important about money to you?

What are you hoping to obtain through this process?

Advisors

Please provide the names of your current professional and personal advisors.

CPA / Tax Preparer Name

Attorney Name

Insurance Agent Name

Friend / Family Advisor Name

Preferred method of contact?

Phone

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