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

  

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 actively switch or reallocate among my portfolio...
at least 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   Spouse's health is: ExcellentGoodPoor
  
  

Assets / Current Holdings:

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

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

  
  Additional Comments/Questions: