Couples Dual Questionnaire

(1)

Investor Profile Questionnaire

Your responses will help us recommend a custom investment program tailored

to your needs.

Clients’ names

How did you hear about us? Are you:  Married  Single

Please complete Sections 1 and 2 separately for each individual. Complete Section 3 together.

Section 1 Contact information

Preferred title (Mr., Mrs., Ms., Dr., etc.)

First name Last name

Date of birth: / / U.S. Citizen:  Yes  No

Street address

City State Zip code

Home phone Work phone Cell phone

Email address

Emergency contact name

Relationship Phone

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(2)

Occupation

 Working  Retired Retirement date: / /

Job title (Last, if retired)

Employer (Last, if retired)

Education

Highest level attended Major

Name of School

Family

Child name Relationship (step, custodial, etc.) Age

(3)

Estate plans

Do you have the following documents? Yes No

Will  

Living trust (Name of trust)  

Power of attorney (Please provide copy)   Name of estate planning attorney  

Financial concerns

Please rank according to your level of concern. 1 2 3 4 5

Outliving my money 1 2 3 4 5

Increasing cost of living 1 2 3 4 5

Beating the market 1 2 3 4 5

Maximizing investment return 1 2 3 4 5

Reducing risk in my portfolio 1 2 3 4 5

Generating additional income 1 2 3 4 5

Paying for long-term care 1 2 3 4 5

Leaving assets to my spouse 1 2 3 4 5

Leaving assets to my heirs 1 2 3 4 5

Protecting my family 1 2 3 4 5

In your own words, what are your main financial concerns?

Needs and goals

What are your main goals?

What do you want your retirement to look like?

Do you believe your current investments are sufficient to achieve your financial goals? Please explain:

What is your desired annual income in retirement?

What is your desired reserve for unexpected retirement expenses?

Not concerned Very concerned

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(4)

Yes No Do you have any large purchases or expenditures planned in the next

3-5 years?  

Purpose: Amount needed: $

Date needed:

Does your employer provide health insurance after you retire?   If yes, will your spouse be eligible to continue on the group plan if

either of you retires before age 65?   Do you have any outstanding debt other than mortgages?   Are you taking required minimum distributions?   Have you ever worked with an advisor or financial planner before?   Please briefly describe your experience:

Do you have a financial plan?  

Section 2 Contact information

Preferred title (Mr., Mrs., Ms., Dr., etc.)

First name Last name

Date of birth: / / U.S. Citizen:  Yes  No

Street address

City State Zip code

Home phone Work phone Cell phone

Email address

Emergency contact name

Relationship Phone

2

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(5)

Occupation

 Working  Retired Retirement date: / /

Job title (Last, if retired)

Employer (Last, if retired)

Education

Highest level attended Major

Name of School

Family

Child name Relationship (step, custodial, etc.) Age

Other dependents

Personal interests

Hobbies Pets Favorite charities Volunteer opportunities

Social or environmental issues of concern

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(6)

Estate plans

Do you have the following documents? Yes No

Will  

Living trust (Name of trust)  

Power of attorney (Please provide copy)   Name of estate planning attorney  

Financial concerns

Please rank according to your level of concern. 1 2 3 4 5

Outliving my money 1 2 3 4 5

Increasing cost of living 1 2 3 4 5

Beating the market 1 2 3 4 5

Maximizing investment return 1 2 3 4 5

Reducing risk in my portfolio 1 2 3 4 5

Generating additional income 1 2 3 4 5

Paying for long-term care 1 2 3 4 5

Leaving assets to my spouse 1 2 3 4 5

Leaving assets to my heirs 1 2 3 4 5

Protecting my family 1 2 3 4 5

In your own words, what are your main financial concerns?

Needs and goals

What are your main goals?

What do you want your retirement to look like?

Do you believe your current investments are sufficient to achieve your financial goals? Please explain:

What is your desired annual income in retirement?

What is your desired reserve for unexpected retirement expenses?

Not concerned Very concerned

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(7)

Yes No Do you have any large purchases or expenditures planned in the next

3-5 years?  

Purpose: Amount needed: $

Date needed:

Does your employer provide health insurance after you retire?   If yes, will your spouse be eligible to continue on the group plan if

either of you retires before age 65?   Do you have any outstanding debt other than mortgages?   Are you taking required minimum distributions?   Have you ever worked with an advisor or financial planner before?   Please briefly describe your experience:

Do you have a financial plan?  

Section 3 Please complete this section together.

Name: Name: Joint

CASH

Checking $ $ $

Savings $ $ $

Money market funds $ $ $

CDs $ $ $

INVESTMENT ASSETS (NONRETIREMENT)

Stocks $ $ $

Bonds $ $ $

Mutual funds $ $ $

Annuities $ $ $

INVESTMENT ASSETS (RETIREMENT) Name:

Total Your annual contribution Employer’s annual contribution

(8)

Name:

Total Your annual contribution Employer’s annual contribution

IRAs $ $ $ Roth IRAs $ $ $ 401(k) $ $ $ 403(b) $ $ $ Pension $ $ $ REAL ESTATE

Titled to Market value Mortgage Primary residence Vacation residence Income property Other INCOME SOURCES Name: Name: Preretirement income Wages or salary Projected increase, if any Business income Pension

Investment income Other (inheritance, etc.) Retirement income Wages or salary Business income Pension Investment income Social Security Start date: / / Other (inheritance, etc.) INSURANCE

Life insurance Insurance company: Name of insured:

Term or permanent  Term  Permanent  Term  Permanent Employer provided  Yes  No  Yes  No Death benefit:

Year purchased: Annual premium:

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(9)

For financial advisor use only.

Yes No

Do you have employer-provided life insurance?   Will it continue after you retire?   Do you have any outstanding debt other than mortgages?   Do you carry long-term care insurance?   Benefit per month:

Do you carry disability insurance?   Benefit per month:

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