personal & confidential€¦ · time horizon: your current situation and future income needs....
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![Page 1: Personal & Confidential€¦ · Time Horizon: Your current situation and future income needs. 1. When do you expect to start drawing income? Not for at least 20 years In 10 to 20](https://reader034.vdocuments.net/reader034/viewer/2022042319/5f0956257e708231d426594e/html5/thumbnails/1.jpg)
Client Questionnaire
Personal & Confidential
®
®
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Client Information As Of:
First Name: (Salutation): Last Name: ________________________________
Date of Birth: _____________________________
Address Line 1: _____________________________ Tax Filing Status: ________________________________
Address Line 2: _____________________________ Previous Marriage(s)?: ________________________________
City: _____________________________ Citizenship: ________________________________
State: __________Zip______________ Alma Mater: ________________________________
Home Phone: _____________________________ (Country) Clubs: ________________________________
Home Fax: _____________________________ Hobbies: ________________________________
Cell Phone: _____________________________ Areas of Interest: ________________________________
Wedding Anniversary: _____________________________ Email: ________________________________
Business Information:
Company: _____________________________ Annual Review: _____/01/_____
Title: _____________________________ or Equity Review: _____/01/_____
Type of Business: _____________________________ Financial Plan Review: _____/01/_____
Business Address: _____________________________ DRIP: _____/01/_____
City: _____________________________ Preferred Mailing Address: Home Business
State: _____________Zip___________ Email Communication: Yes No
Work Phone: _____________________________ Holiday Card: Yes No
Human Resources Contact: _____________________________ Newsletter: Yes No
Spouse/Partner
First Name: __________ (Salutation)_______ SPOUSE/PARTNER BUSINESS INFORMATION
Last Name: _____________________________ Company: ________________________________
Date of Birth: _____________________________ Title: ________________________________
Type of Business: ________________________________
Previous Marriage(s)?: _____________________________ Business Address: ________________________________
Citizenship: _____________________________ City: ________________________________
Areas of Interest: _____________________________ State: ___________Zip________________
Hobbies: _____________________________ Work Phone: ________________________________
Email: ________________________________
Children
Name Date of Birth School/Grade Special Needs/Interests
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Advisors (Attorney, Accountant, Personal Banker, Stockbroker, Etc.)
Advisor Type: _______________________________
Name (First Last): _______________________________
Company: _______________________________
Address: _______________________________
City: _______________________________
State: ___________Zip
Phone: _______________________________
Fax: _______________________________
Email: _______________________________
Advisor Type: ____________________________
Name (First Last): _______________________________
Company: _______________________________
Address: _______________________________
City: _______________________________
State: ____________Zip________________
Phone: _______________________________
Fax: _______________________________
Email: _______________________________
Advisor Type: _______________________________
Name (First Last): _______________________________
Company: _______________________________
Address: _______________________________
City: _______________________________
State: ___________Zip
Phone: _______________________________
Fax: _______________________________
Email: _______________________________
Advisor Type: ____________________________
Name (First Last): _______________________________
Company: _______________________________
Address: _______________________________
City: _______________________________
State: ____________ Zip________________
Phone: _______________________________
Fax: _______________________________
Email: _______________________________
Family Goals
Please list the three most important goals that you would like to accomplish as a result of working with TriBridge Partners, LLC.
1. ________________________________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________________________________
Property
Name
Fair
Market
Value
Tax Basis Current
Liability**
Mortgage
Rate
# of
Years
Left
Ownership
H/W.J/TIC* Address
Primary
Home
See page 1
Second
Home
Investment
Property
Other
* H: Husband W: Wife J: Joint TIC: Tenants in Common ** Mortgage and/or Home Equity
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Personal Property (Art, Jewelry, Cars, Etc.)
Description
Current Value
Ownership
H/W/J/TIC*
Bank Accounts Cash & Cash Equivalents (Checking, Savings, Cds, T-Bills)
Account Name
Account Type
(Checking, Savings,
CD, Money Market)
See
Attached
Statement
Current Value
Ownership
H/W/J/TIC*
□
□
□
□
□
□
Investments (Non-Qualified)
Account Name
See
Attached
Statement
Current Value
Ownership
H/W/J/TIC*
□
□
□
□
□
□
* H: Husband W: Wife J: Joint TIC: Tenants in Common
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Investments: Private Equity
Name
See
Attached
Statement
Amount
Committed/
Cost Basis
Ownership
H/W/J/TIC*
Remaining
Capital
Calls
Nature of
Company
□
□
□
□
Retirement Accounts: (401[K], Ira, Profit Sharing, Deferred Compensation, 403[B] Pension, Sep)
Account Name Account
Type**
Current
Value
See
Attached
Statement
Ownership
H/W* Beneficiary
□
□
□
□
□
□
**Please indicate 401(k): IRA; Profit Sharing, Deferred Compensation, 403(b); Pension; or SEP
Children’s Accounts: Ugma, 529, Trust
Account Name
Account Type
(UGMA, 529,
Trust)
See
Attached
Statement
Current Value Beneficiary
□
□
□
□
□
□
* H: Husband W: Wife J: Joint TIC: Tenants in Common
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Annuities: Fixed, Variable
Account
Name
Annuity
Type
Investment
Co.
See
Attached
Statement
Cash Value
(F/V)
Tax Basis
(F/V)
Ownership
H/W/J/TIC*
Anticipated
Annuitization
Age
Annuities: Immediate
Account
Name
Annuity
Type
Investment
Co.
Annual
Payment
Exclusion
Ratio
Ownership
H/W/J/TIC* Start/End Age
Start: End:
Start: End:
Stock Option And Rsu’s Worksheets
OPTION AND RESTRICT STOCK UNIT GRANTS □ See Statement
Grant
Date Grant Type # Shares
Exercise
Price
(Options
Only)
First
Vesting
Date
Vesting
Frequency
# of
Vesting
Periods
Expiration
Date
Business Interests
Business Name
Fair
Market
Value
Tax
Basis
Business
Type
Percent
Ownership
Spouse
Active?
Children
Involved?
Future Plans
for Business
(For any business provide Insurance Documents) * H: Husband W: Wife J: Joint TIC: Tenants in Common
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LIFE INSURANCE
(1) (2) (3) (4)
Insured
Insurance Company
Policy Type (Term; WL;
VL; UL; etc.)
Purchase Date
Death Benefit
Annual Premium
Policy #
Cash Value
Owner
Beneficiary
Premium Due Date
Desired income in the event of your death? __________________________ Spouse’s Death? __________________________
DISABILITY INCOME INSURANCE
(1) (2)
Insured
Insurance Company
Policy Type (Individual: BOE; Buyout, Group)
Purchase Date
Monthly Benefit
Annual Premium
Policy #
Waiting Period
Benefit Period
COLA Adjustment ( Yes / No ?)
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Long Term Care Insurance
Insured Insurance
Company
Purchase
Date
Daily
Benefit
Annual
PremiumPolicy #
Waiting
Period
Benefit
Period
COLA
Adjustment
(Yes/No?)
Premium Due
Date
Other Insurance Policies (Automobile, Homeowner’s, Umbrella Policy)
Type of Insurance
(Auto, Home,
Umbrella)
Carrier Policy # Amount Premium Deductible
Income Sources: (Salary, Bonus, Pension, Social Security, Sale Of Business)
Name
Income Source
Amount
Comment**
Start/End Age
Start:
End:
Start:
End:
Start:
End:
Start:
End:
Start:
End:
Start:
End:
1. AMT: Are you subject to AMT?: Yes / No
2. Do you/will you support anyone else? Parents, siblings, in-laws?
Assumptions
Client Retirement Age:__________ Spouse Retirement Age: __________
** (e.g. Bonus amounts paid in cash vs. stock)
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Expense
We suggest you fill in this expense list as best as you can (round numbers and approximations are fine) to give yourself a true picture of your monthly/annual expenditures. This is done to give more accuracy to any cash flow model that we will focus on.
Monthly Annually
Mortgage or Rent Payments (Primary Home)
Mortgage or Rent Payments (Other Real Estate)
Real Estate Property Taxes
Maintenance/Common charges
Utilities (electric, cable)
Telephone, cell phone
Private School/Education/College
Food
Clothing
Associations/Dues
Car/Travel Expenses (car pmt, gas, tolls, parking)
Insurance: Home & Auto
Health
Life, Disability Income & LTC
Travel (plane flights, lodging, car rental, etc.)
Recreation and Entertainment (includes dining out)
Child Care/Nanny
Landscaping
Professional fees (accountant, attorney)
Housekeeper
Country Club or other memberships
Charitable Contributions
Gifts (incl. Christmas, birthdays, weddings, baby)
Savings / Investments
Savings for Education
Miscellaneous
Retirement Plan Contributions
Alimony, Child Support
Total Expenses
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Expenses: Living And Other Expenses (Education, Weddings, Charity, Major Purchases, Etc.)
Current Annual Living Expenses:
Other Extraordinary
Expenses (Be Specific)* Amount Comment Start/End Age
Start: _____________________
End:
Start: _____________________
End:
Start: _____________________
End:
Start: _____________________
End:
Start: _____________________
End:
Start: _____________________
End: _____________________
*Education, Weddings, Charity, Major Purchases
Current Plan: Wills & Trusts
Client □ No Will Spouse □ No Will □ Do you have an Irrevocable Trust?
□ Simple Will □ Simple Will
□ Unified Credit Planning □ Unified Credit Planning
Current Plan: Gifting
Comments
Do you or your spouse plan to gift in the future? Yes No
Would you consider using gifting as a planning tool? Yes No
If so, expected number of gift recipients:
Have you or your spouse ever filed a gift tax return? Yes No
Current Plan: Charitable Requests
Name: Name:
Amount Gifted Per Year: Amount Gifted Per Year:
Current Plan: Savings Plan
Do you contribute to a 401(k) plan? Yes No Amount/ year: Company Match Yes No
Does your spouse contribute to a 401(k) plan? Yes No Amount/ year: Company Match Yes No
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Risk Assessment Questionnaire
The Risk Assessment Questionnaire helps to determine the best asset mix for an investment, based on the answers given to the questions below.
Time Horizon: Your current situation and future income needs.
1. When do you expect to start drawing income? Not for at least 20 years In 10 to 20 years In 5 to 10 years Not now, but within 5 years Immediately
Long-Term Goals and Expectations: Your views of how an investment should perform over the long term.
2. What is your goal for your investments? To grow aggressively To grow significantly To grow moderately To grow with caution To avoid losing money
3. Assuming normal market conditions, what would you expect from your investments over time? To generally keep pace with the stock market To slightly trail the stock market, but make a good profit To trail the stock market, but make a moderate profit To have some stability, but make modest profits To have a high degree of stability, but make small profits
4. Suppose the stock market performs unusually poorly over the next decade, what would you expect from this investment? To lose money To make very little or nothing To eke out a little gain To make a modest gain To be little affected by what happens in the stock market
Short-Term Risk Attitudes: Your attitude toward short-term volatility.
5. Which of these statements would best describe your attitudes about the next three years' performance of this investment? I don't mind if I lose money I can tolerate a loss I can tolerate a small loss I'd have a hard time tolerating any losses I need to see at least a little return
Short-Term Risk Attitudes:
6. Which of these statements would best describe your attitudes about the next three months' performance of this investment? Who cares? One calendar quarter means nothing I wouldn't worry about losses in that time frame If I suffered a loss of greater than 10%, I'd get concerned I can only tolerate small short-term losses I'd have a hard time stomaching any losses
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Goals:
1. Ideal “retirement age”
2. Ideal family size if known (current plan)
3. Major purchases (e.g. home upgrade, second home, major projects, education expenses)
4. Education for children (public/private K-12 and/or college)
5. How would your life change if your spouse passed away (financially/ work hours/ living situation)
6. What amount are you currently saving on an annual basis and what would be a realistic target?
7. Any other relevant financial goals:
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Notes:
www.tribridgepartners.com | 240.422.8799 (local) | 855.333.6399 (toll-free)
One East Pratt Street | Suite 902 | Baltimore, MD 21202 6550 Rock Spring Drive | Suite 190 | Bethesda, MD 20817 5280 Corporate Drive | Suite C250 | Frederick, MD 21703
38 South Potomac Street | Suite 303 | Hagerstown, MD 21740
BCC2706 815