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