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INVESTMENT PROFILE QUESTIONNAIRE
This comprehensive, personal financial summary is designed to help you take inventory and assign realistic values to your personal assets and
liabilities. It is the essential first step in organizing your financial future, and it is our goal is to help you make the right decisions for your financial
future. The information you provide in this questionnaire will assist us in making sound recommendations with confidence.
AGENT INFORMATION
First Name
Last Name Email Address
Mobile Phone
CLIENT INFORMATION (Please Include both Spouses names)
100
Client First Name
Last Name
Age
Birth Date
Spouse First Name
Last Name
Age
Birth Date
Resident Address
City
State
Zip
Home Phone
Cell Phone
How did you hear about us?
OCCUPATION
Client Job Title
Employer (last if retired) # of years Desired Retirement Date
Spouse Job Title
Employer (last if retired)
# of years
FAMILY ASSETS
* Indicate whether the assets is owned by you, a second person, or jointly.
** Indicate whether the purpose of the asset is for cash reserves, education, an accumulation goal, or retirement.
Personal
Owner*
Current Value
Primary Residence
$
Vacation home/Second Residence
$
Rental Property
$
TOTAL PERSONAL ASSETS
$
This comprehensive, personal financial summary is designed to help you take inventory and assign realistic values to your personal
assets and liabilities. It is the essential first step in organizing your financial future, and it is our goal to help you make the right
decisions for your financial future. The information you provide in this questionnaire will assist us in making sound recommendations
with confidence.
Desired Retirement Date
0
Liquid And Investments
Owner*
Purpose**
Current Value
Checking/Savings/Money
$
C.D.s
$
Life Insurance (Cash Value)
$
Life Insurance (Cash Value)
$
Brokerage Account (Non-Q)
$
Brokerage Account (Non-Q)
$
TOTAL LIQUID AND INVESTMENT ASSETS
$
Retirement
Owner*
Purpose**
Current Value
Current Employer 401(k), 403(b), 457(b)
$
Current Employer 401(k), 403(b), 457(b)
$
IRA 401(k), 403(b), 457(b), self-directed
$
IRA 401(k), 403(b), 457(b), self-directed
$
IRA 401(k), 403(b), 457(b), self-directed
$
IRA 401(k), 403(b), 457(b), self-directed
$
Annuities
$
Annuities
$
Other Retirement Assets
$
Other Retirement Assets
$
TOTAL RETIREMENT ASSETS
$
TOTAL ASSETS – (equals total of liquid assets and retirement assets)
$
FAMILY LIABILITES
*** Indicate whether the debtor of the liability is you, a second person, or both.
Original Balance
Current Balance
Mortgage on First Residence
$ $
Mortgage on Second Residence
$ $
Charge/Credit Cards
$ $
Other Liabilities
$ $
Total Liabilities
$
Market
0
0
0
0
FAMILY INCOME
ANNUAL INCOME
CLIENT
SPOUSE
Employment (wages, salaries, bonuses)
$
$
Self-Employment/Business Income
$
$
Social Security Benefits
$
$
Other Government Benefits
$
$
Taxable Investment Income
$
$
$
$
$
$
$
$
Rental Income
Pensions (if Currently Receiving)
Other Income - Taxable
Other Income – Non-Taxable
$
$
TOTAL ANNUAL INCOME
$
$
APPROXIMATE MONTHLY HOUSEHOLD EXPENSES
Fixed
$
Variable
$
TOTAL
$
GENERAL
Are you anticipating any major lifestyle changes?
(I.E. Marriage, Divorce, Retirement, Moving, Etc.
Yes
No
Uncertain
If so, what changes are you expecting?
Are you comfortable with your current cash flow?
Yes
No
Uncertain
Do you anticipate any significant changes in your cash flow?
Yes
No
Uncertain
Do you anticipate any major expenditures in the near future?
Yes
No
Uncertain
If so, what expenditures are you expecting?
GOALS
Protection from Market Risk
Immediate Income
Tax Deferral
Potential for better rate
Wealth Accumulation
Estate Planning
Retirement Income
Death Benefit
Other
Total Annual Income
COMBINED
$
What are you primary reasons for creating a retirement plan?
(I.E. RMD's, Dividends)
0
0
0
0
RISK PROFILE
How much money would you be willing to lose next year and still be comfortable?
Name -
$
%
Name -
$
%
CONCERNS
Please list any concerns you may have:
AGENT NOTES
Please provide information that would assist us with designing the proper benefit plan (I.E. If they want to
start Guaranteed Lifetime Income):
DESIRED INCOME
What is the needed amount of income annually? When ideally would client want to start receiving?
Annual Amount -
$
Estimated Date of Income -
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Completed 4 December 2020

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