Initial Interview Form To make the best use of our time together please complete and return this form to us before our meeting. Date: Name Person 1:*FirstLast Current Age Person 1:* E-mail Person 1:* Phone Person 1:* Area Code - Phone Number Profession Person 1:* Employer Person 1:* Address: Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Name Person 2:FirstLast Current Age Person 2: Phone Person 2: Area Code - Phone Number E-mail Person 2: Employer Person 2: Profession Person 2: Do you have a will?YesNo Do you have a Living Trust?YesNo Do you have Life insurance?YesNo Whole Life ($): Term ($): Do you have an asset protection trust?YesNo Do you have long-term care insurance?YesNo Do you own any real estate in your own name?YesNo Do you Track Personal Expenses?YesNo What do you use to track your personal expenses?QuickbooksQuickenMSN MoneyManually Do you have a retirement plan?YesNo Retirement Plan Type:IRA401KMPPPDB PlanOther Do you have a small business?YesNo Type of Business:Sole ProprietorPartnershipLLCS-CorpC-CorpOther Have you Funded your Children's Education?YesNo Education Funding:UGTMA529CoverdellPersonal SavingsOtherINCOME**Please use whole numerical values only, not symbols, commas or decimals. Salary/Wage Income (Before Taxes):* Social Security/Pension Income (Before Taxes):* Annual Savings/Retirement Plan Contributions:*ASSETS**Please use whole numerical values only, not symbols, commas or decimals. Annuities: Savings, Money Market, CDs College Savings (529/Coverdell Plans) Taxable Investments (Stocks, Bonds, Options, REITS, Mutual Funds Employer Pensions Plans (Defined Benefit, MPPP, Profit Sharing) Investment Real Estate (Office Buildings, Rental Properties) IRAs, Roth IRAs, SEPs 401K, 403b, 457, TSP, Simple Personal Property: Closely Held Business Interests(Partnerships, Corporations, Limited Partnerships) Home Second, Vacation Homes Total Assets**:$ **If TOTAL ASSETS is blank, please check the fields in the assets section to make sure you only used numerical values, no symbols, commas, or decimals.LIABILITIES**Please use whole numerical values only, not symbols, commas or decimals. Home Mortgage (First, Seconds, HELOCs) Consumer Loans (Credit Cards, Student Loans, Car Loans, Etc.) Investment Real Estate or Business Loans Total Liabilities:$ **If TOTAL LIABILITIES is blank, please check the fields in the liabilities section to make sure you only used numerical values, no symbols, commas, or decimals.NET WORTH Total Net Worth (Assets less Liabilities)$ 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 PlanningTotal: 0/21 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?SubmitReset (This will erase all data entered)
