Registered Representative of and securities and investment advisory services offered through Cetera Advisor Networks LLC, member FINRA/SIPC. Some advisory services are offered through AdvisorNet Financial. Cetera Advisor Network, AdvisorNet Financial, and Sterling Retirement Resources are not affiliated. This information will be used to prepare an individual report assessing your current
financial needs. Your responses will not be sold or shared with any unaffiliated parties. 8401 Golden Valley Road, Suite 225
Golden Valley, MN 55427
Main: 763.762.3400 • Fax: 763.762.3409 www.sterlingretirement.com
-2-
Congratulations on your desire and commitment towards planning for a successful
financial future. Before we can begin our analysis, we ask you to complete the
following questionnaire and return it to our office, along with the following
documents listed below. All documents will be returned and all information will be
held in the strictest confidence.
Please furnish us with the following information:
Bank account statements (checking, savings, money markets)Investment statements (Brokerage statement(s), Mutual Fund statement(s), Certificate of Deposit statements, IRAs, 401K, 403B, Pension, Stock Option statement)
Most recent statement(s) for Annuity policy(s) AND copy of policy(s) Last year’s tax return and W-2(s)
Last year’s property tax returns for ANY/ALL real estate
Will(s), Trust(s), Power(s) of Attorney, Living Will(s), or Health Care Directive(s) Date Last Reviewed _____________________
Most recent statement(s) for life insurance policy/policies AND copy of policy/policies Disability policy/policies. If group disability, “Summary Plan Description” is needed Long Term Care policy/policies
Company benefits (most companies publish a benefits booklet/statement) Pension statement(s)
Two consecutive months’ payroll stubs (to include explanation of deductions) Social Security Benefit statement(s)
Copy of Mortgage(s) statement(s) AND Mortgage Note(s) Homeowner and automobile insurance policy(s)
Loan and Liability statement(s)
-3- Full Legal Name
Please include middle initial
______________________________ _______________________________
Social Security Number ______________________________ _______________________________ Driver’s License ______________________________ _______________________________ Issuing State _____________ Exp ____________ _____________ Exp _____________ Date of Birth ______________________________ _______________________________
Home Address Line 1 ______________________________ _______________________________ OR Same Address as Client
Home Address Line 2 ______________________________ _______________________________ City ______________________________ _______________________________ State _______ Zip Code ______________ _______ Zip Code _______________ Home Phone ______________________________ _______________________________
Cell Phone ______________________________ _______________________________ Work Phone ______________________________ _______________________________ Personal Email ______________________________ _______________________________ Professional Email ______________________________ _______________________________
Preferred Email? Personal Professional email Personal Professional email I/we would like meeting notes
to be delivered via: Email Mail Both
Marital Status Single Married Divorced Widowed Employment Status Employed Homemaker Retired
Not Currently Employed
Employed Homemaker Retired
Not Currently Employed
Employer Name ______________________________ ______________________________ Work Address ______________________________ ______________________________ City, State, Zip Code ______________________________ ______________________________ Current Position/Title ______________________________ ______________________________
-4-
Children and Grandchildren
Name: ________________________________SS#: Birth Date: _________________
Spouse Name: ____________________________________ State of Residency: ________________________________
(Your Children: Name ___________________ DOB ________ Name ___________________ DOB _________ Grandchildren) Children: Name ___________________ DOB ________ Name ___________________ DOB _________
Name: ________________________________SS#: Birth Date: _________________
Spouse Name: ____________________________________ State of Residency: ________________________________
(Your Children: Name ___________________ DOB ________ Name ___________________ DOB _________ Grandchildren) Children: Name ___________________ DOB ________ Name ___________________ DOB _________
Name: ________________________________SS#: Birth Date: _________________
Spouse Name: ____________________________________ State of Residency: ________________________________
(Your Children: Name ___________________ DOB ________ Name ___________________ DOB _________ Grandchildren) Children: Name ___________________ DOB ________ Name ___________________ DOB _________
Name: ________________________________SS#: Birth Date: _________________
Spouse Name: ____________________________________ State of Residency: ________________________________
(Your Children: Name ___________________ DOB ________ Name ___________________ DOB _________ Grandchildren) Children: Name ___________________ DOB ________ Name ___________________ DOB _________
Parents
Client 1’s Parents:
Name(s) and Age(s) ___________________________________________________________________ Health Concerns: ___________________________________________________________________ State of Residency: _________________
Is their estate in order? Yes No
Comment: ___________________________________________________________________
Client 2’s Parents:
Name(s) and Age(s) ___________________________________________________________________ Health Concerns: ___________________________________________________________________ State of Residency: __________________
Is their estate in order? Yes No
Comment: ___________________________________________________________________
-5- 1. Hobbies/Interests/Organizations/Clubs: Client 1: _____________________________________________________________________________ Client 2: _____________________________________________________________________________ 2. Health Concerns: Client 1: _____________________________________________________________________________ Client 2: _____________________________________________________________________________ 3. Financial Commitments (Previous Marriage, Outstanding Loans, etc.):
Client 1: _____________________________________________________________________________ Client 2: _____________________________________________________________________________ 4. Is there a possibility that other people, such as a parent, might become financially dependent upon you?
Yes No If yes, please explain: ____________________________________________________ 5. Are there any special considerations that relate to your children and their future (e.g. Disabilities, Second
Marriages, or Financially Unskilled Children)?
Yes No If yes, please explain:____________________________________________________
Other Important Information:__________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Name Phone Number Satisfied?
Financial Planner Yes No
Stockbroker Yes No
Attorney Yes No
Accountant Yes No
Life Insurance Agent Yes No
Home/Auto Agent Yes No
Who would you consult first on an important financial decision? _______________________________________
Family Background
-6-
At Sterling, we are committed to providing our clients with broad-based financial planning. To be the most effective partner in helping you to achieve your goals, please select which goals and objectives are important to
you.
From the list above, please tell us which three are the most important to you now by indicating their number below: 1._________ 2._________ 3._________
Is there anything we haven’t asked you that we should discuss?_________________________________________ ____________________________________________________________________________________________ What is the most important thing you hope to get from this process? ____________________________________ _____________________________________________________________________________________________ What do you like most/least about your present financial position? ______________________________________ _____________________________________________________________________________________________ If you were going to make improvements in your financial plan, what steps would you take?__________________ _____________________________________________________________________________________________ If we were meeting three years from today, and you were to look back over those three years, what has to have happened during that period, both personally and professionally, for you to feel happy about your progress? _____________________________________________________________________________________________ _____________________________________________________________________________________________ Client 1 Client 2 1. Establish a savings plan, accumulate wealth
2. Become financially able to retire
3. Taking care of self and family during a period of long-term disability/long-term care 4. Design an investment strategy for: ___________________________________________ 5. Professional management of my investment portfolio
6. Reduce income taxes
7. Provide funds for college education for children/ grandchildren 8. Provide for my family's cash and income needs in the event of death 9. Prepare estate plan, protect estate for heirs, reduce taxation upon death 10. Provide for continuation/sale of business as a result of death or disability
11. Other: ________________________________________________________________
-7-
When would you like to retire? First enter your Target Retirement Age, then indicate how willing you are to delay retirement beyond that age if it helps you reach your Lifestyle Goals.
Client 1 Client 2
Target Retirement Age _______ OR Retired Now _______ OR Retired Now How willing are you to retire
later (if necessary) to attain your goals? Not at all Slightly Willing Somewhat Willing Very Willing Not at all Slightly Willing Somewhat Willing Very Willing
Lifestyle Goals are above and beyond what you need to pay for the basic expenses of day-to-day living. Dream a little (or a lot), and create all the goals you would like, even if you’re not sure you can afford them. Only include separate goals not accounted for in the Retirement and Education Goal sections.
Travel - Recurring Vacations Wedding - Celebration
Cars - Transportation Gifts - Donations – Leave Bequest
Health Care for Yourself or Others New Home - Vacation Home - Renovations
Start a Business Other Major Purchases
Importance
Description and Details
Start
Target Amount How Often How Many Times High 10 Low 1 Year At Retirement
8 Example: Annual Travel Fund $12,000 Yearly 20
Target Retirement Age
-8-
The following questionnaire will help us determine an investment strategy that best fits your needs. If completing with a spouse or partner, please use the first column for Client 1 response and the second column for Client 2 response. This questionnaire can be completed before or during your next meeting.
1) When do you expect to START withdrawing money from your investment portfolio?
A. Currently or within 2 years B. 2 to 4 years
C. 5 to 8 years D. 8 to 12 years E. 12 or more years
3) If your investment portfolio worth $500,000 started losing value, at which point would you START to become uncomfortable?
A. $490,000 B. $475,000 C. $450,000 D. $400,000 E. $350,000 F. $300,000 or lower
2) Once withdrawals start, how long will you need the withdrawals to last?
A. Less than 2 years B. 2 to 5 years C. 6 to 10 years D. 11 to 15 years E. 15 or more years
4) If the same investment portfolio continued to lose value, at which point would you ask your advisor to reduce your risk level?
A. $490,000 B. $475,000 C. $450,000 D. $400,000 E. $350,000 F. $300,000 or lower 5) If the choices below represented the best and worst possible outcomes for a
$500,000 portfolio invested for five years, which portfolio would you choose?
Worst Case Best Case
A. $550,000 $670,000 B. $500,000 $720,000 C. $450,000 $800,000 D. $400,000 $950,000
6) Which of the following statements best describes your attitude towards investment (market) risk? A. I prefer taking a high level of risk in a portfolio that seeks significant growth.
B. I prefer taking a significant level of risk in a portfolio that seeks growth.
C. I prefer taking a moderate level of market risk in a portfolio that seeks growth and income. D. I prefer taking a low level of market risk in an attempt to limit market losses.
E. I prefer taking no investment risk in an attempt to avoid losing any capital.
Client 1 Client 2 Client 1 Client 2
