Contact Information:

Name:         
Address:    
City:       
State:      
Zip Code:   
Email:      
Home Phone:   
Work Phone: 
Your Age:        Spouse's Age:
Number of children:   Number of grandchildren: 

Your Philosophies on Money Management, Taxes & Financial Planning:

Which best describes your overall activity in the past 12 months?
I did not add to my portfolioI added to my overall portfolioI withdrew more than I added

Which best describes your overall attitude towards investing and risk?  
I am generally willing to accept:

 Wide price fluctuations in return for maximum long-term gains
 Moderate price fluctuations for conservative gains
 Virtually no price fluctuations for a guarantee of principal and income

What is your employment status? Full TimePart TimeRetiredUnemployed

Your Occupation: 
Your Spouse:     
Desired Age of Retirement: 
Your Spouse:               

Gross household income last year? $25-50,000$50-100,000$100-150,000$150-250,000$250,000 & Above

My Federal Tax Bracket is: 15%28%31%36%39.6%
			     
My State Tax Bracket is:   15%28%31%36%39.6%

General awareness level of stock/bond market activites: HighMediumLowVery Low

Do you own mutual funds?   Yes    No  

If yes, do you spend or reinvest the earnings?   Spend    Reinvest

I reallocate my portfolio: OneTwoThreeOver Five time(s) per year.

Your favorite money managers are: No PreferenceAIMAllianceAlgerAmerican CapitalAmerican CenturyBabsonBergerBlanchardCalvertCappiello RushmoreCohen & SteersColonialDavisDean WitterDodge & CoxDreyfusEaton VanceEnterpriseEvergreenFederatedFidelityFortisFoundersFranklinGT GlobalGabelliGuardianHartfordHeritageIAIIDEXInvescoJanusKaufmanKemperLindnerLoomis SaylesMFSMerrill LynchMontgomeryMutual SeriesNationwideNeuberger & BermanNicholas ApplegateNorwestNuveenOakmarkOberweisOppenheimerPBHGPIMCOPainewebberParnassusPiper JaffrayPrudentialRobertson StephensRushmoreSaloman BrothersSchwabScudderSeligmanSequoiaSmith BarneyStein RoeStrongTempletonThird Ave ValueTweedyThornburgUSAAValue LineVan EckVanguardVontobelWaddell & ReedWarburg PincusWeiss, Peck & GreerYacktmanZweig  

Which investment newsletters/periodicals do you subscribe to: NoneBusiness WeekFinancial WorldKiplingerPhillips PublishingSmart MoneyMoney MagazineU.S. News & World ReportWall Street JournalOther

What type of investments do you generally prefer:StocksBondsMutual FundsReal EstateOther

Are you contributing to Qualified Retirement Plan?  Yes    No 
  
If so, what type: 401k403(b)IRARoth IRASARSEPSEPSimple IRASimple 401kProfit Sharing

You are accustomed to average returns on your investments of:5-10%10-15%15-20%Better

Who do you rely upon for financial input or advice? SelfCPAAttorneyInsurance BrokerInvestment BankerFee-only PlannerOther
						      
Your primary concerns are: Retirement PlanningTax ReliefAsset AccumulationCurrent IncomeEstate PlanningCollege FundingDebt ConsolidationOther
  
Asset Protection & Estate Planning Information:

Do you have a Will?   Yes    No   
Do you have a Living Trust?   Yes    No 
Do you have a Long Term Care Policy?   Yes    No

Do you have a Disability Insurance Policy?   Yes    No
Have you established a Uniform Gift to Minors Trust?   Yes    No
Do you have an Irrevocable Trust?   Yes    No

Do you have a Family Limited Partnership?   Yes    No
Are you an income beneficiary of a family trust?   Yes    No
Are you currently gifting?   Yes    No

Do you have a handicapped family member?   Yes    No
Are you working with an estate planning specialist or attorney?   Yes    No    
Are you in a second or third marriage?   Yes    No

Do you have children from a previous marriage?   Yes    No
Do you own life insurance?   Yes    No	

My health is: ExcellentGoodPoor
My spouse's health is: ExcellentGoodPoor
  
Assets / Current Holdings:

Residence  $ 
Other real estate interests  $ 

Non-Tax Qualified Assets (Non IRA)
Annuities  $ 
Liquid Assets  $ 
Mutual Funds  $ 
Stocks  $ 
Bonds  $ 
Other  $ 

Tax-Qualified Assets (IRA, 401k, Pension)
Annuities  $ 
Liquid Assets  $ 
Mutual Funds  $ 
Stocks  $ 
Bonds  $ 
Other  $ 
Business Interests  $ 
Personal Property (Collectibles, art, coins, etc.)  $ 
Life Insurance total cash value  $ 
Other  $ 

Totals:

Estimated gross estate value  $ 
Liabilities (mortgages, notes, etc.)  $ 
Net Estate Value  $ 

Additional Comments/Questions: