Client Questionnaire Date Completed: Client Name: Co-Client Name: Relationship to Co-Client: Relationship to Client: Date of Birth: Date of Birth: Gender: F M Gender: F M U.S. Citizen: U.S. Citizen: Home Address: Home Address: City, State, Zip: City, State, Zip: Home Phone: Home Phone: Work Phone: Work Phone: Cell Phone: Cell Phone: Fax (Home or Work): Fax (Home or Work): Email: Email: Primary person to contact during business hours: Preferred contact method: Home Phone Cell Phone Email Family Members (please list children and other dependents): Name: Relationship: Date of Birth: Dependent: Resides (city & state): Short-term goals (next 1-5 years): Financial Planning Goals & Objectives Longer-term goals: What would you like to accomplish with Direction Financial Management? Page 1 of 7
How would you like your money to work for you? For example: charity, family security, bequests, education, or anything not listed above. What makes you uneasy about your finances? What would you like to change? Employment Information, including self employment (if applicable): Client Co-Client Employer: Employer: Position: Position: Number of years with this employer: Number of years with this employer: Anticipated employment changes? Yes No Anticipated employment changes? Yes No When do you plan to retire? When do you plan to retire? Current salary: $ Current salary: $ Self-employed income: $ Self-employed income: $ Other earned income: $ Other earned income: Average bonus/commissions: $ Average bonus/commissions: $ Total annual income = $ Total annual income = $ Is income consistent & reliable? Yes No Is income consistent & reliable? Yes No Do you have non-employment sources of income, such as alimony, pensions, retirement accounts, royalties or rental property? If yes, please describe: Do you know what your annual living expenses are? Please provide an estimate. Do you have a cash management plan (budget)? Are you saving for big ticket items (car, vacation, home repairs, etc.)? Are you saving for your child s college education? If yes, please provide the amount saved per year. Expenses/Budgeting: Page 2 of 7
Advisor Relationships Where applicable, rate your current advisor on a scale of 1 (dissatisfied) to 5 (very satisfied) Advisor Rating (1-5) Comment Accountant Tax Preparer Attorney Broker Insurance Agent (1) Insurance Agent (2) Financial Planner Tax & Estate Planning Information Who prepares your tax return? Self Paid Preparer Preparer Name: Client: Which documents do you have? Year drafted? In what state? Will Living Will Living Trust Durable Power of Attorney (Financial) Durable Power of Attorney (Medical) Other (e.g. property agreements) Co-Client: Which documents do you have? Year drafted? In what state? Will Living Will Living Trust Durable Power of Attorney (Financial) Durable Power of Attorney (Medical) Other (e.g. property agreements) Insurance Information If you have information regarding anything indicated below you may submit copies of the appropriate documents instead of entering the information below. Policy Insurance company Coverage Amount? Deductible? Premium? Vehicle 1 $ Vehicle 2 $ Vehicle 3 $ Homeowners $ Umbrella Liability $ Page 3 of 7
Have you ever been turned down for insurance? Yes No Premium? Client Do You Have? Employer- Provided? Coverage? Health: Yes No Yes No Disability: Yes No Yes No Life: Yes No Yes No Umbrella Liability: Yes No Yes No Long-Term Care: Yes No Yes No Co-Client Do You Have? Employer- Provided? Coverage? Health: Yes No Yes No Disability: Yes No Yes No Life: Yes No Yes No Umbrella Liability: Yes No Yes No Long-Term Care: Yes No Yes No Have you ever been turned down for insurance? Yes No Premium? Financial Assets If you have information regarding anything indicated below you may submit copies of the appropriate documents instead of entering the information below. Bank Accounts (Checking (C), Savings (S), Money Mkt (MM), Other (O) Bank Name Type of Account Interest Rate Ownership Avg. Balance (C,S,MM,O) Indiv,Jt,Trust Certificate of Deposits (CDs) Institution Interest Rate Maturity Date Ownership Avg. Balance % Page 4 of 7
Retirement Savings (IRAs, Roth IRAs, 401(k)s, etc.) Account Name Type of Account Owner Current Current Balance Contribution Employer Match Do you contribute the maximum amount allowed each year to your employer-sponsored retirement plan? Client Yes No Co-Client Yes No Do you save at least 10% of your annual salary? Client Yes No Co-Client Yes No Do you have a pension? Client Yes No Co-Client Yes No If yes, estimated monthly benefit: Client $ at age Co-Client $ at age. Do the pensions have a COLA? Client Yes No Co-Client Yes No Other Investment Accounts Attach a copy of your most current brokerage, mutual fund, college savings and retirement statements. Please list below an estimate of any other investment assets not appearing on the list above or the statements provided (such as savings bonds or an employee stock purchase plan): Do you manage your own investments? Yes No Page 5 of 7
What is your desired annual retirement income? (after tax, in today s dollars) $ Personal Property Primary Residence: $ Secondary Residence: $ Vehicle 1: $ Vehicle 2: $ Vehicle 3: $ Business Property: $ Furnishings: $ Other: $ Other: $ Estimated Value: Notes: Personal Liabilities Credit Cards: (If not paid in full each month) Name Interest Rate Average Monthly Payment Current Balance $ $ $ $ $ Other Debts: Type Term Maturity Date Interest Rate Monthly Payment Current Balance 1 st Mortgage 2 nd Mortgage Home equity Auto Loan #1 Auto Loan #2 Student Loan Other Other Original Balance Have you received a copy of your credit report recently? Yes No If you know your credit score, what is it? Client: Co-Client: Are there any other obligations to be considered such as alimony, child support, etc.? Page 6 of 7
Other Other noteworthy considerations not captured above: These items, as well as others, may be needed should you engage our services: Prior year tax return Paycheck stubs Brokerage account statements Mutual fund account statements Trust account statements Legal documents Loan documents Employee benefits booklet Insurance policies Social Security Statements Please e-mail this completed form to: diane@directionforyou.com or Mail to: Direction Financial Management, LLC W177 N9856 Rivercrest Drive, Suite 214 Germantown, WI 53022 or request a ShareFile link by e-mailing: diane@directionforyou.com Thank you for the time you have taken to provide this information! I look forward to meeting you soon. Page 7 of 7