Initial Interview Form To make the best use of our time together please complete and return this form to us before our meeting. Initial Interview Form Step 1 of 5 20% Date MM slash DD slash YYYY Name Person 1:(Required) First Last Current Age Person 1:(Required)Please enter a number from 18 to 100.E-mail Person 1:(Required) Phone Person 1:(Required)Profession Person 1:(Required) Employer Person 1:(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name Person 2: First Last Current Age Person 2:Please enter a number from 18 to 100.Phone Person 2:E-mail Person 2: Employer Person 2: Profession Person 2: Do you have a will? Yes No Do you have a Living Trust? Yes No Do you have Life insurance? Yes No Whole Life ($): Term ($): Do you have an asset protection trust? Yes No Do you have long-term care insurance? Yes No Do you own any real estate in your own name? Yes No Do you own any real estate in your own name? Yes No Do you Track Personal Expenses? Yes No What do you use to track your personal expenses? Quickbooks Quicken MSN Money Manually Do you have a retirement plan? Yes No Retirement Plan Type: IRA 401K MPPP DB Plan Other Do you have a small business? Yes No Type of Business: Sole Proprietor Partnership LLC S-Corp C-Corp Other Have you Funded your Children's Education? Yes No Education Funding: UGTMA 529 Coverdell Personal Savings Other INCOME **Please use whole numerical values only, not symbols, commas or decimals. Salary/Wage Income (Before Taxes):(Required)Social Security/Pension Income (Before Taxes):(Required)Annual Savings/Retirement Plan Contributions:(Required)ASSETS **Please use whole numerical values only, not symbols, commas or decimals. Annuities:Savings, Money Market, CDsCollege Savings (529/Coverdell Plans)Taxable Investments (Stocks, Bonds, Options, REITS, Mutual FundsEmployer Pensions Plans (Defined Benefit, MPPP, Profit Sharing)Investment Real Estate (Office Buildings, Rental Properties)IRAs, Roth IRAs, SEPs401K, 403b, 457, TSP, SimplePersonal Property:Closely Held Business Interests(Partnerships, Corporations, Limited Partnerships)HomeSecond, Vacation HomesTotal Assets**: Please prioritize the financial assistance you are seeking (1-Top Priority, 2-Second....6-lowest):Asset & Income ProtectionInvestment Strategy PlanningRetirement PlanningFinancial Coaching/CounselingCash Flow Management (i.e. Spending Plan, Budgeting)Estate PlanningTotalTotal should be less than 21 Tell us about your most important financial concerns and what you would like to accomplish through this engagement.Tell us about your most important non-financial concerns right now?Describe how you envision your lifestyle 5 years from now. (What are you doing or becoming, where, how, etc)Describe previous experiences working with financial advisors or financial therapists. What was good/unsatisfactory?Tell us how you make important financial decisions? Tell us about future financial changes that you wish to plan for. (i.e. family obligations /inheritances...)During our review 3 years from now, what will need to have happened for you to be satisfied with your progress?Tell us about past litigation involvements. What happened?Describe your ideal relationship with a financial planner or financial therapist.Is there anything else we need to talk about?Where did you hear about us? Δ
