ConfidentialQuestionnaire

1、 CONFIDENTIAL QUESTIONNAIRE for The purpose of this form is to help you in gathering the basic information about your current financial situation which we will need in order to make the best use of our time together. Without knowing everything one is doing financially, it is next to impossible to di

2、scuss options available because what may be right in one set of circumstances may be harmful in another. Please bring this questionnaire along with the documents listed on the back of this form to your next interview. All information provided will be strictly confidential. Your Full Name Date of Bir

3、th Birth Place Social Security Number Spouse (Full Name) Date of Birth Birth Place Social Security Number Child Date of Birth Birth Place Social Security Number Child Date of Birth Birth Place Social Security Number Child Date of Birth Birth Place Social Security Number Your Reside nceStreet & No. C

4、ity State Zip Home Teleph one Emerge ncy Teleph one Name Cell Phone Email Address Yours (title) Employer Employer Address City State Teleph one Len gth of Service (years) Current Base Salary Bonus $ $ Spouse (title) Employer Employer Address City State Teleph one Len gth of Service (years Current Ba

5、se Salary Bonus $ $ In terest Rate Mon thly Payme nt (in clud ing taxes) Prin cipal In terest Mon ths Remai ning Mortgage Un paid Bala nce Your Reside nce % $ $ $ $ Other Home % $ $ $ $ Other Real Estate % $ $ $ $ Purchased Year / Price Own ership (join tly, etc.) Improveme nts Capital Expe nditures

6、 Curre nt Market Value (estimate) Your Reside nce $ $ Other Home $ $ Other Real Estate $ $ Item In stituti on Joi ntly Held Yourself Spouse Child Savings Account $ $ $ $ Savings Bonds (type) $ $ $ $ Sin gle Premium Deferred Annuity $ $ $ $ IRA $ $ $ $ 401K / Ann ual Co ntribution $ $ $ $ Compa ny Ma

7、tch $ $ $ $ Perso nal Profit Shari ng Pla n $ $ $ $ How much are you savi ng on a mon thly basis? $ $ $ $ Number of Shares Item Name Joi ntly Held Yourself Spouse Child Stocks / Bon ds $ $ $ $ $ $ $ $ $ $ $ $ Mutual Funds $ $ $ $ $ $ $ $ $ $ $ $ Item Name Joi ntly Held Yourself Spouse Child $ $ $ $

8、$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Name of Compa ny Family Member In sured Premium Amo unt Cash Value Policy Loa ns Amount of Coverage $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Bank Cards (Visa, MasterCard, Discover, America n Express, Other) $ $ Yes / No $ $ Yes / No $ $ Yes / No $ $ Yes / No 1

9、Store Charges (Sears, JCPenney, Other) $ $ Yes / No $ $ Yes / No $ $ Yes / No Other $ $ Yes / No $ $ Yes / No Bank Loa ns (other tha n mortgage, e.g., auto, home improveme nt, home equity, educati on, etc.) $ $ Yes / No $ $ Yes / No $ $ Yes / No $ $ Yes / No Additi onal Comme nts:(Other factors that

10、 could be importa nt to your finan eial positi on.) Type of Loa n Mon thly Payme nt In sured? Y/N Mon ths Rema iningLoa n Un paid Bala nee Please bring to your first meeting: 匚 Paycheck Stubs 匚 Compa ny Ben efit Booklet 匚 Compa ny Ben efit Stateme nt or Summary 匚 Statements on all Investments / Securities, plus accompanying prospectus 匚 Wills & Trust Documents 匚 Bank Statements 匚 Tax Return -most recent 匚 In sura nee Policies 匚 Medical 匚 Life 匚Car 匚 Umbrella 匚 Home 匚 Disability In come 匚 Other: 匚 Other: DOCUMENT RECEIPT: I have received the above checked docume nts