FINANCIAL PROFILE QUESTIONNAIRE
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	Personal Information:
*	Last Name:
	First Name	Middle
	Date Of Birth:	MM DD Year
	Gender:	Male Female
*	Email:
*	Tel. (home):
	Work:
	Fax:
	Home Address:
	City/State	Choose a State Outside US / Canada Alabama Alaska Alberta Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
	Zip
	Employment Information:
	Profession
	Annual Income
	Years of Service
	Value of Personal Assets in ($US):
	Renting
	Own a Home
	Years in Residence
	Monthly Payment
	Value of Property:
	Mortgage Balance
	Years Remaining:
	Value of Automobile
	Car Note Balance
	Other Assets
	Liabilities (in $):
	Home Equity Loan
	Credit Cards
	Unsecured Debts
	Other Debts
	Retirement Assets Information (in $US):
	Employer-Sponsored Plan (401k, 403b, Profit Sharing etc.)
	Current Balance
	Monthly Contributions
	Employer Match
	Self-Directed Plan: (Roth IRA, Traditional IRA, Annuities, etc)
	Current Balance
	Monthly Contributions
	Self-Employment Accounts (SEP, Keogh Plan, Annuities):
	Current Balance
	Monthly Contributions
	Investments and Insurance (in $US)
	Checking
	Savings
	Money Market
	Equities (stock, mutual funds
	Fixed Income (Bonds/Structured products)
	Other investments
	Life Insurance	Yes No
	Face Amount	Term Variable Whole Life
	Monthly Premium
	Disability Insurance	Yes No
	Monthly Benefit
	Monthly Premium
	Health Insurance	Yes No
	Employer-sponsored	Yes No
	Financial Goals:
	Desired Retirement Goal
	Desired Retirement Life Style (in $US)
	Desired Survivor Lifestyle (in $US)
	Are you currently investing?	Yes No
	Investment Risk:	Conservative  Moderate Aggressive
	Future Inheritance
	Major Concerns/Long-term Objectives:
	Saving for retirement
	Saving For College
	Asset Protection
	Long-Term care
	Long-term disability
	Home Ownership
	Investment Property
	Other Concerns/Objective
	Comments/Instructions:
	Provide any helpful information that will help us serve you or make our service better.