Confidential Client Profile Questionnaire Confidential Client Profile Questionnaire Step 1 of 9 11% Marital StatusSingleMarriedDivorcedWidowedName* First Middle Last Date of Birth Date Format: 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 Date Format: 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?YesNoInsurerDo you own Life Insurance?YesNoInsurerDo you own Health Insurance?YesNoInsurerDo you own Disability Insurance?YesNoInsurerDo you have a Will?YesNoLast updatedDo you have a Trust?YesNoLast updated Beneficiary InformationName First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY Name First Last RelationshipDate of Birth Date Format: MM slash DD slash YYYY Retirement GoalsCheck all that apply Income Income + Growth Growth Aggressive Growth Additional commentsConcerns or FearsCheck all that apply Inflation Pandemic Running Out of Money Additional comments IncomeEmployerSpouse EmployerSpouse Current Gross Annual SalaryCurrent Gross Annual SalaryProjected Retirement Date Date Format: MM slash DD slash YYYY Spouse Projected Retirement Date Date Format: 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. Owner1. IRA/Non-IRA1. Investment Type1. Account Value2. Owner2. IRA/Non-IRA2. Investment Type2. Account Value3. Owner3. IRA/Non-IRA3. Investment Type3. Account Value4. Owner4. IRA/Non-IRA4. Investment Type4. Account Value5. Owner5. IRA/Non-IRA5. Investment Type5. Account Value6. Owner6. IRA/Non-IRA6. Investment Type6. Account Value7. Owner7. IRA/Non-IRA7. Investment Type7. Account Value8. Owner8. IRA/Non-IRA8. Investment Type8. Account Value Annuities1. Owner1. Company1. IRA/Non-IRA1. Payout?1. Account Value2. Owner2. Company2. IRA/Non-IRA2. Payout?2. Account Value3. Owner3. Company3. IRA/Non-IRA3. Payout?3. Account ValueOtherGold, Silver, Cash, Coins, etc... Real Estate1. Owner1. Company1. Description1. Value2. Owner2. Company2. Description2. Value3. Owner3. Company3. Description3. 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
