NevadaBenefits.com Confidential Financial Planning Questionnaire

"When Trish told me to keep what I had, I was shocked! I had called three other agents and they all tried selling me something that wouldn't have covered me. I'll keep giving you guys all my referrals. At least I can feel good about giving people your number."
- Kelly in Las Vegas, NV

"When I looked at my financial plan you guys prepared, I almost fell over. I'm way off! You got me back on track (I will max out my 401K, I promise!)."
- Roger via Email

After you complete the following information, we will compile this information into our financial planning program.

Confidential Questionnaire

Date of Completion
Client Name (1)
Home Address:
City, State, Zip:
Home Phone:
Work Phone:
Fax: (Home/Work)
E-Mail:
Birth Date:
Client Name (2)
Home Address:
City, State, Zip:
Home Phone:
Work Phone:
Fax (Home/Work)
E-Mail:
Birth Date:
Primary Contact Person during business hours?

Family Members ( Please list children and other dependants)

Name	Relationship	Date of Birth	Dependent	Resides (City & State)
			Y N
			Y N
			Y N
			Y N
			Y N

Retired?

Y N

Social Security:

Total Monthly Income:

Client (1) Employer:
Title/Job:
Number of years with this employer:
Anticipated employment changes?
When do you plan to retire?
Salary:
Self Employment Income:
Bonus/Commissions:
Other Earned Income:
Total (Current year):
Client (2) Employer:
Title/Job:
Number of years w/this employer:
Anticipated employment changes:
When do you plan to retire:
Salary:
Self Employment Income:
Bonus/Commissions:
Other Earned Income:
Total (current year):

Who prepares your tax return?

Self
Paid Preparer (If paid preparer please list)
Name:
Address:
Phone:
Fax:

Do you have estate planning documents?	When and in what state were they drafted?
Wills Y N
Living Trust Y N
Power of Attorney Y N
Living Will Y N
Other Documents Y N

How were your current investment assets selected?

Indicate which of the following statements summarize your attitudes or beliefs using a scale of 1-5. (1 being most true and 5 least true)

	I would rather work longer than reduce my standard of living in retirement.
	I feel that I/we can reduce our current living expenses to save more for the future if needed.
	I am more concerned about protecting my assets than about growth.
	I feel comfortable with aggressive growth investments.
	I don't like surprises.
	My immediate concern os for income rather than growth opportunities.
	I am a risk taker.
	I usually pick the tried and true, the slow, safe but sure investments.
	I need to focus my investment efforts on building cash reserves.
	I prefer predictable, steady return on my investments, even if the return is low.

In order of priority, Summarize your prime objectives:

Special Goals:

Risk Preference:

Low Risk												Aggressive
	0	1	2	3	4	5	6	7	8	9	10

What experiences have you had with investments?

How often would you like to be contacted?

Do you want to be on our mailing list for monthly newsletters, client update meetings and specials?

Y N

Client (1)

Insurance	Coverage	Group	Individual
Health
Disability
Disability
Life
Life
Life
Homeowners
Auto
Auto
Umbrella Liability
Professional Liability
Long Term Care
Jewelry or Furs
Have you ever been turned down for insurance?		Y N
Have you used tobacco products in the past 2 years?		Y N

Client (2)

Insurance	Coverage	Group	Liability
Health
Disability
Disability
Life
Life
Life
Homeowners
Auto
Auto
Umbrella Liability
Professional Liability
Long Term Care
Jewelry or Furs
Have you ever been turned down for insurance?		Y N
Have you used tobacco products in the past 2 years?		Y N

ASSETS

Bank Accounts
Bank Name	Checking, Savings or Money		Ownership	Average Balance
				$
				$
				$
CD's
Where Held?	Interest Rate	Maturity Date	Ownership	Apx. Value
	%			$
	%			$
	%			$

401 (K)'s, IRA's, ROTH's

Please list below and estimate a value for any other investment assets not appearing on the list above.

Do you expect any inheritances?

When?

Estimated


Personal Property	Estimated Value
Primary Residence
Furnishings (Liquidation Value)
Vehicle
Vehicle
Other
Other

Liabilities

Credit Cards	Interest Rate*	Average Monthly Payment	Current Balance
	%	$	$
	%	$	$
	%	$	$
	%	$	$

* If not paid in full each month

Debt (Residence, auto, business, school)	Interest Rate	Payment	Current Balance
	%	$	$
	%	$	$
	%	$	$
	%	$	$

Have you received a copy of your credit report recently? Y N

Please comment on the advice you seek:

Depending on the level of services requested, these items may be needed, should you engage our services:

Prior year tax return	Paycheck stubs
Brokerage account statements	Mutual funds account statements
Trust account statements	Employee benefits booklet
Retirement plan account statements	Legal documents
Loan documents	Insurance policies

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