Confidential Client Profile Questionnaire Confidential Client Profile Questionnaire Step 1 of 9 11% Marital Status Single Married Divorced Widowed Name* First Middle Last Date of Birth MM slash DD slash YYYY Home PhoneCell PhoneEmail* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Spouse’s Name First Middle Last Spouse’s Date of Birth MM slash DD slash YYYY Spouse’s Home PhoneSpouse’s Cell PhoneSpouse’s Email Spouse’s Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Professional Contact InformationAccountant Name First Last Accountant Email Accountant PhoneEstate Planning Attorney Name First Last Estate Planning Attorney Email Estate Planning Attorney PhoneOther InformationDo you have Long Term Care Insurance? Yes No Insurer Do you own Life Insurance? Yes No Insurer Do you own Health Insurance? Yes No Insurer Do you own Disability Insurance? Yes No Insurer Do you have a Will? Yes No Last updated Do you have a Trust? Yes No Last updated Beneficiary InformationName First Last Relationship Date of Birth MM slash DD slash YYYY Name First Last Relationship Date of Birth MM slash DD slash YYYY Name First Last Relationship Date of Birth MM slash DD slash YYYY Name First Last Relationship Date of Birth MM slash DD slash YYYY Retirement GoalsCheck all that apply Income Income + Growth Growth Aggressive Growth Additional commentsAdvisor(s)How would you rate your current advisor? 1 (lowest) to 10 How often do you have a review of your plan? What do you want from your advisor?Concerns or FearsCheck all that apply Inflation Pandemic Running Out of Money Additional comments IncomeEmployer Spouse EmployerSpouse Current Gross Annual SalaryCurrent Gross Annual SalaryProjected Retirement Date MM slash DD slash YYYY Spouse Projected Retirement Date MM slash DD slash YYYY Social Security BenefitsSpouse Social Security BenefitsPensionSpouse PensionSurvivor PensionSpouse Survivor PensionReal EstateSpouse Real EstateInvestment IncomeSpouse Investment Income Assets(Investment types: stocks, bonds, mutual funds, CD’s, checking, savings, money market)1. Owner 1. IRA/Non-IRA 1. Investment Type 1. Account Value2. Owner 2. IRA/Non-IRA 2. Investment Type 2. Account Value3. Owner 3. IRA/Non-IRA 3. Investment Type 3. Account Value4. Owner 4. IRA/Non-IRA 4. Investment Type 4. Account Value5. Owner 5. IRA/Non-IRA 5. Investment Type 5. Account Value6. Owner 6. IRA/Non-IRA 6. Investment Type 6. Account Value7. Owner 7. IRA/Non-IRA 7. Investment Type 7. Account Value8. Owner 8. IRA/Non-IRA 8. Investment Type 8. Account Value Annuities1. Owner 1. Company 1. IRA/Non-IRA 1. Payout? 1. Account Value2. Owner 2. Company 2. IRA/Non-IRA 2. Payout? 2. Account Value3. Owner 3. Company 3. IRA/Non-IRA 3. Payout? 3. Account ValueOtherGold, Silver, Cash, Coins, etc... Real Estate1. Owner 1. Company 1. Description 1. Value2. Owner 2. Company 2. Description 2. Value3. Owner 3. Company 3. Description 3. Value ValuesBelow is a sample of values often expressed. This list is intended to inspire you, not limit your self expression: Freedom, Energy, Generosity, Faith, Happiness, Honor, Security, Respect, Joy, Adventure, Independence, Comfort, Peace of Mind, Love, Recognition, Fulfillment, Creativity, Abundance, Dignity, BeautyMy top 3 value wordsSpouse top 3 value words Δ
