Prospect Questionnaire

Contact and General Information

Your Information

How did you hear about us?

Your Name:

Birthdate:

Street Address:

City

State

ZIP Code

Cell Phone Number:

Primary Email Address:

Are you retired?

YesNo

At what age would you like to retire?

Employer:

Occupation:

Your Total Income:

Do you have a significant other?

YesNo

Co-Client Information

Co-Client's Name:

Co-Client's Birthdate:

Co-Client's Cell Phone Number:

Co-Client's Primary Email Address:

Is the Co-Client retired?

YesNo

At what age would they like to retire?

Co-Client's Employer:

Co-Client's Occupation:

Co-Client's Total Income:

Do you have dependent children?

YesNo

Child's Information

Name

Age

Goals, Objectives, and Concerns

All planning should begin and end with your personal considerations and goals. To help us better understand yours, please number the following in order of their importance to you, with (1) indicating the greatest importance. There are 10 items. If any of the options are of little to no value to you, simply leave them blank.

Account consolidation and simplification

Business and succession planning

Caring for elderly parent, relative, or special needs child

Cash flow planning and cash flow optimization

Charitable planning and supporting interest in charities

College planning for (grand)child

Diversifying a concentrated stock position

Legacy and multi-generational planning for children/grandchildren

Retirement planning and maintaining a comfortable lifestyle

Tax planning by optimizing current and future taxes

Other Concerns, Goals, and Objectives

What other important wealth plan concerns, goals, or objectives do you have?

Cash Flow Worksheet

Would you like to complete the cash flow worksheet?

YesNo

Cash Flow

Please fill out the following fields with annual income amounts:

Annual Income

Your Employment Income	Co-Client's Employment Income
Your Pension Income	Co-Client's Pension Income
Your Social Security Income	Co-Client's Social Security Income
Your Business/Self-Employment Income	Co-Client's Business/Self-Employment Income
Your Rental/Passive Income	Co-Client's Rental/Passive Income

Total Income

Expenses

Monthly Expenses

Annual Expenses

Annual Savings

Please fill out the following fields with annual saving amounts:

Your Employer Retirement Plan Contributions

Co-Client's Employer Retirement Plan Contributions

Your Roth IRA Contributions

Co-Client's Roth IRA Contributions

Your Traditional IRA Contributions

Co-Client's Traditional IRA Contributions

Your Brokerage Account Contributions

Co-Client's Brokerage Account Contributions

College Savings

General Savings

Total Savings

Total Monthly Surplus Including Taxes Paid

Total Annual Surplus Including Taxes Paid

Would you like to complete a customized Personal Net Worth Statement?

YesNo

Asset Worksheet

Please fill out the following fields with the specified item's current value using positive whole numbers with no commas or dollar signs. If you do not have a balance for the specified account, please feel free to leave it blank.

Cash Equivalents

Your Cash Balance	Co-Client Cash Balance
Your Checking & Savings Balance	Co-Client Checking & Savings Balance
Your Money Market Balance	Co-Client Money Market Balance
Your CD Balance	Co-Client CD Balance

Investment Assets

Your 401k/403b Balance	Co-Client 401k/403b Balance
Your Traditional IRA Balance	Co-Client Traditional IRA Balance
Your Roth IRA Balance	Co-Client Roth IRA Balance
Your Brokerage Account Balance Your Annuity Balance	Co-Client Brokerage Account Balance Co-Client Annuity Balance

Tangible Assets

Primary Residence Value	Secondary/ Vacation Residence Value
Personal Property Value	Rental Property(ies) value
Auto #1 Value	Auto #2 Value
Auto #3 Value	Other Tangible Assets Value

Business Assets

Business Building Value

Business Value

Liabilities Worksheet

Please fill out the following fields with the specified item's current balance using positive whole numbers with no commas or dollar signs. If you do not have a balance for the specified account, please feel free to leave it blank.

Personal Loans

Primary Residence Mortgage	Secondary/Vacation Residence Mortgage
Home Equity Line of Credit	Student Loans
Credit Card Debt	Personal Loans
Auto Loans	Business Loans
Rental Real Estate Mortgage(s)	Other Debt

Your Personal Net Worth Statement

Assets

Total Cash Equivalents

Total Investment Assets

Total Tangible Assets

Business Total Assets

Liabilities

Total Liabilities

Your Total Net Worth

Total Net Worth

If you completed the Net Worth Statement Worksheet on the previous page, your personalized Net Worth Statement should be above.

Once you have completed this form, please review your entries and then submit using the button below. If you have any questions, please call our team at 513-984-6696. Thank you!