Confidential Questionnaire Please return this to me at least 3 days before our scheduled meeting. Personal Information Client Name Address —Please choose an option—AKALAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Phone Number E-mail Birthdate Marital Status/Date U.S. Citizen? Co-Client Name Address —Please choose an option—AKALAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Phone Number E-mail Birthdate Marital Status/Date U.S. Citizen? Preferred Method of Contact PhoneEmail Preferred Phone Number (Please number 1, 2, & 3) Home Work Cell Children/Dependents Name Birthdate Address Relationship Employment Information Client Employer Title/Job Anticipated changes? When do you plan to retire? Will you have a pension? Stock Options/RSUs? Co-Client Employer Title/Job Anticipated changes? When do you plan to retire? Will you have a pension? Stock Options/RSUs? Income Client Salary Bonus/Commissions Self-employment income Pension Social security Other income Total: Co-Client Salary Bonus/Commissions Self-employment income Pension Social security Other income Total: Taxes Are all federal and state taxes up to date and filed on time? YesNo Are any of your income tax filings on extension? YesNo Who prepares your tax returns? 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
