State / Province / Region
Postal / Zip Code
1) Your date of birth:
2) Your partner’s date of birth:
3) Your children/dependent(s) date(s) of birth:
4) Do you and/or your partner have adult children who are financially dependent and/or living at home?
5) Your planned age @ retirement (default = 65):
6) Your partner's planned age @ retirement (default = 65):
7) Your current average gross annual income & sources of income:
8) Your occupation:
9) Your partner's current average gross annual income & sources of income:
10) Your partner's occupation:
11) Percent of current gross household income needed in retirement (default = 70%):
12) Do you have any special plans for retirement (e.g., start a business, travel extensively, collect rare works of art?)
13) Do you own your home, or do you rent?
Questions 14 to 21
IF YOU OWN YOUR HOME OR ARE BUYING ON CONTRACT, please answer questions 14 through 20. IF YOU ARE RENTING YOUR HOME, please skip to question 21.
14) Current market value and/or appraised value of your home (your best estimate is OK):
15) Dollar value of your equity in your home:
16) Amount you still owe on your home:
17) Size of monthly payments on your mortgage or contract:
18) Extra monthly amounts if any added to required minimum mortgage payment?
19) Type, maturity, and interest rate(s) of your mortgage(s) (e.g., fixed rate, variable rate, balloon payment, 15-year, 30-year). Please include home equity loans or lines of credit:
20) Do you plan to pay off your mortgage early? When (best estimate is ok)?
21) How much is your monthly rent?
22) Are you saving for retirement? If yes, on your own or through work (401k/403b/457/profit share/stock-purchase)? How much? How frequently? Does your employer provide a matching payroll contribution or a periodic profit-sharing contribution? How much?
23) Value of each of your investment accounts (stocks, bonds, mutual funds, IRAs, 401(k), 403(b), and other employment related retirement/savings plans. etc. [please attach account statements showing the breakdown of investments and ongoing contributions if possible]):
24) Approximate nature and value of any other assets such as rental properties, collectible items, farmland, life insurance, etc.:
25) Please describe other non-mortgage/home equity debt or financial obligations such as student loans, personal loans, credit card balances:
26) Are your parents still living? Age(s)? Overall health? Do they have long term care insurance?
27) Are your partner’s parents still living? Age(s)? Overall health? Do they have long term care insurance?
28) Are any parents (or anyone else) likely to become financially dependent upon you?
29) Percent of gross income (or $$ amount) planned for regular charitable giving or tithing to a church? Planned increases/decreases?
30) Are you (is everyone in your immediate family) covered by health insurance? Individual, family, or workplace plan? Amount of your deductible per person/household? Co-insurance percentage? Stop-loss?
31) Annual health care spending/any major, extraordinary, or chronic illnesses or other health conditions?
32) Do you and/or your spouse/partner own long term care insurance? If so, please describe the policy benefits:
33) Are you covered by life insurance? If so: Who owns it? What kind is it (term or permanent)? How much is the death benefit? Who else is covered (spouse/partner/children)? Who/what is the beneficiary? Is your life insurance individually owned or part of a workplace plan? Who pays some/all of the premium? Is the death benefit pledged or collateralized, or can it be claimed by any entity other than your intended beneficiary?
34) Is your spouse/partner covered by life insurance?
35) Do you own or are you covered at work by disability insurance (insures against loss of income)? If so, who pays the premium? You, your employer, or both? Please describe the benefits:
35) If you yes describe
36) Is your spouse/partner covered by disability insurance?
37) Do you have difficulty meeting your monthly bills/expenses?
38) Do you regularly save money weekly/biweekly/monthly/annually in addition to your retirement/college savings (how much/how often/where)?
39) Do you maintain a liquid, readily accessible, emergency fund? How much (default recommendation = three times monthly income)? Where? Is it subject to investment risk of any kind?
40) What is the current value of all FDIC-insured bank deposits, including Certificates of Deposit, checking, and savings?
41) Are there any major short-term (within the next few years) spending needs such as car purchase, home purchase, college funding, etc.? Please list:
42) Are there any major impending changes in your life, such as marriage, divorce, adoption, moving your residence, bankruptcy, changing jobs, retirement, planned or otherwise?
42) If you yes describe
43) Are there moral, ethical, social, or spiritual issues, not included in your social and environmental investment policy questionnaire, that I should take into consideration?
43) If you yes describe
44) Do you plan to, or would you like to, leave a legacy or estate for anyone or anything after you die? If so, do you have an estate plan?
45) Do you have an up-to-date in-force Last Will and Testament?
46) Other pertinent information not yet asked for: