Client Questionnaire

Personal & Confidential

®

®

2

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

3

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

4

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

5

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:

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