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Confidential Financial Questionnaire
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Confidential Financial Questionnaire
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Family Status:
Single
Married
Divorce
Your Legal Name
DOB
Spouse's Legal Name
DOB
Your Children's Name
DOB
Your Children's Name
DOB
Children's Name
DOB
Children's Name
DOB
Health Condition
Poor
Good
Do you have the following?
Living Will
Last Will & Testament
Trust
Corporation
Address
City
State
Zip code
Email Address
Spouse's Email Address
Your Cell Phone #
Spouse's Cell Phone #
Occupation / Income / Retirement
Your Occupation
Length of Service
Length of Service
Current Salary $
Retired
Yes
No
Spouse's Occupation
Employer
Length of Service
Current Salary $
Retired
Yes
No
Do you typically receive a tax refund?
Yes
No
how much? $
$ Your Bonus(s)
Other Income:
$ Social Security Income
Other Income:
$ Rental Property
Other Income:
$ Investment Income
Other Income:
$ Investment Income
Other Income:
$ Other Income
Other Income:
If not retired, at what age do you expect to retire?
Other Income:
$ Spouse's Bonus(s)
Other Income:
$ Other Income
Other Income:
$ Interest Income
Other Income:
$ Notes Receivable
Other Income:
Spouse's Retirement Age Goal?
Other Income:
Checking + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Cash+ Low Risk – At Risk (copy)
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Savings + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Money Mkt + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
CD's + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Annuities + Low Risk – At Risk (copy)
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Ret. Accts + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Expenses Monthly Jointly
Pre. Metals + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
Brokage Accts + Low Risk – At Risk
+
–
Assets (Circle + or – as your risk tolerance)
Yours $
Enter the value $
Spouse's $
Enter the value $
Jointly Held $
Enter the value $
-At Risk %
+ Low Risk %
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Monthly Expenses
Total Monthly Expenses X 12
Total Annual Expenses X12
Life Insurance Company
Insurance
$ Death Benefit Amount
Type WL, UL, IUL, or Term
$ Annual Premium
Life Insurance Company
Insured
$ Death Benefit Amount
Type WL, UL, IUL, or Term
$ Annual Premium
Life Insurance Company
Insured
$ Death Benefit Amount
Type WL, UL, IUL, or Term
$ Annual Premium
Insured
$ Death Benefit Amount
Type WL, UL or Term
$ Annual Premium
Other Insurance (Disability, Long-Term Care, etc.)
Insured
$ Monthly Benefit Amount
Type WL, UL or Term
$ Annual Premium
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Credit Cards
Other Misc Debt
Other Misc Debt
Other Misc Debt
Other Misc Debt
Auto Loan
Auto Loan
Auto Loan
Auto Loan
Student Loan
Student Loan
Student Loan
Student Loan
Other
Other
Other
Other
$ Current Mortgage
$ Unpaid Balance
# Months Remaining
% Interest Rate
$ Monthly Payment
$ Second Mortgage
$ Unpaid Balance
# Months Remaining
% Interest Rate
$ Monthly Payment
$ Other Mortgage
$ Unpaid Balance
# Months Remaining
% Interest Rate
$ Monthly Payment
Please circle your lookout toward taking risks with your money.
Conservative
Moderate
Moderately Aggressive
Aggressive
Risk Tolerance / Desires
Has your retirement account ever lost money due to market volatility or a market correction? How did it make you feel?
1
2
3
4
5
6
7
8
9
10
0= Not Concern 5 = Somewhat Nervous 10= Very Concern
Your Answer is
If your account dropped 22% in one day as the DJ 30 did on October 19, 1987, how would you feel?
1
2
3
4
5
6
7
8
9
10
0= Not Concern 5 = Somewhat Nervous 10= Very Concern
Your Answer is
How much can you afford to lose without the loss affecting your current lifestyle?
Zero%
10%
20%
30%
40%
Your Answer is
Do you now have your retirement account protected from loss?
Yes
No
Is your account protected from fees and commissions?
Yes
No
% What inflation rate percentage are you using for your calculation to project your future retirement money?
Suppose you could participate in some of the upswings of the market without ever having to worry about the negative effects of the market on your retirement account value. Would this be a major benefit to you?
Yes
No
Would you sleep better at night knowing you could never lose value again in your retirement account or any other account that you may own?
Yes
No
Which of the following are your top three concerns? (Pick only three)
Losing too much money in the stock market
Avoid paying too much in taxes
Considering retirement and not sure if I/we can afford to
Not having a reliable income plan for retirement
Concern about giving away life savings due to catastrophic illness
Outliving my nest egg (money)
Uncertainty about our government, economy, and stock market
Leaving a legacy to children and/or grandchildren
Concerned with losing money in retirement accounts
After answering these questions, has your risk tolerance changed? (Circle Your Position)
Conservative
Moderate
Moderately Aggressive
Aggressive
Risk Tolerance / Desires
Checking
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
Social Security
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
Qualified Accts
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
CD's
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
Money Markets
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
Precious Metals
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
Other Cash
When You Retire, or if You Are Retired, Please Indicate the Priority of Your Withdrawals for Spending: Example: #1 Checking, #2 Social Security Income, #3 Your Qualified Accounts Give Ranking to the Following:
Agrees to provide the following documents:
*
Please collect the documents listed below and forward them to me at your earliest convenience. Last Two Years’ Tax Returns • Disability, Major Medical, and Long-Term Care policies Auto Declaration Page Home Declaration Page • Account Statements: IRA, 401k, 401a, 403b, 457, ROTH IRA, Brokerage Accounts Life Insurance & Annuity Policies (for review) Any other document of importance to you
Your Dream List
Spouse's List
Notes or Questions
My job is to help you find the money that you now may now be giving away to others from your circle of wealth unknowingly and unnecessarily, to improve your monthly cash flow and your cash flow after you retire, and to seek better benefits for you and your family, helping you to adjust your risk profile to meet your comfort level. My mission is to accomplish all of this without you spending one more dime out of pocket than you are currently spending.
Client's Signature
Date:
Spouse's Signature
Date:
Tommy Lee Ruff, CLUⓒ ChFCⓒ
Submit
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