Confidential Questionnaire

Please return this to me at least 3 days before our scheduled meeting.

    Personal Information

    Client


    Address




    Phone Number





    Co-Client


    Address




    Phone Number





    Preferred Method of Contact

    Preferred Phone Number

    (Please number 1, 2, & 3)

    Children/Dependents

    Name Birthdate Address Relationship

    Employment Information

    Client






    Co-Client






    Income

    Client







    Co-Client







    Taxes


    YesNo

    YesNo

    SelfPaid PreparerOther

    Estate Planning Information

    Client Co-Client Year State
    Will YesNo YesNo
    Living will YesNo YesNo
    Durable power of attorney YesNo YesNo
    Health care power of attorney YesNo YesNo
    Trusts YesNo YesNo
    Other YesNo YesNo

    Insurance

    Client Co-Client Amount
    Term life insurance YesNo YesNo
    Employer provided life insurance YesNo YesNo
    Health insurance YesNo YesNo
    Long term care YesNo YesNo
    Long term disability YesNo YesNo
    Homeowners insurance YesNo YesNo
    Auto insurance YesNo YesNo
    Umbrella insurance YesNo YesNo
    Professional liability YesNo YesNo

    Personal Property

    Estimated Value Original Purchase Price
    Primary residence
    Vacation home
    Rental Property
    Auto 1
    Auto 2
    Other

    Liabilities (unless linked via RightCapital)

    Credit cards

    Credit Card Interest Rate Ave. monthly payment Balance

    Other Debt

    Type Interest Rate Ave. monthly payment Balance