e-mail: rkahnfinplan@earthlink.net

Appointment Date:___________ Time:___________ Referred by:_____________

Your Name:________________________________ Date of Birth:____/___/____

Employer/Profession:_________________________ Bus.#:__________________

Spouse/Partner’s Name:______________________ Date of Birth:____/___/____

Employer/Profession: _________________________ Bus.#:__________________

Home Address:___________________________________________________________

Home #: (_____)____-_____ Fax #: (_____)____-_____ Pgr/Mbl: (_____)____-_____

E-mail: ________________ What is the best way to contact you:__________________

Child: 1.____________________ Date of Birth: _____/_____/_____

2.____________________ Date of Birth: _____/_____/_____

3.____________________ Date of Birth: _____/_____/_____

1. How did you hear about

Accumulation Strategies?______________________________________

2.What is your primary goal, concern and/or motivation for contacting a financial planner at this time?

________________________________________________________________________________________________________________________________________________

3.What are your most important financial concerns?

A)_____________________________________________________________________

B)______________________________________________________________________ C)______________________________________________________________________

4.What are your most important non-financial concerns & objectives right now or if you were to accomplish #2 above what would it mean to you personally?

A)_____________________________________________________________________

B)_____________________________________________________________________

C)_____________________________________________________________________

5. Do you or your spouse/partner have any of the following?

Health Insurance_____ Long Term Care Insurance_____

Medicare Supplement_____ Disability Insurance______

Wills_____ Trusts_____ Life Insurance_____ Mutual Funds_____

Stocks_____ Bonds_____ Managed Accounts_____

Family Owned Business____________ Investment Real Estate____________

6. Who makes important investment decisions in your family?_____________________

7. Who do you currently get financial adivce from? _____________________________

8. Have you ever worked with a financial advisor before? Yes_____ No_____

What was good about that experience?________________________________________

_______________________________________________________________________

Unsatisfactory?__________________________________________________________

_______________________________________________________________________

9. Below are listed some of the potential benefits of our professional services. Please check the benefits you feel would be the most helpful to you in achieving your objectives. Please note that some of these services will be done in conjunction with an attorney or accountant.

1. ___ Establish a savings plan to accumulate wealth
2. ___ Plan for my children's/grandchildren's education
3. ___ Professional help in selecting investments
4. ___ Professional management of my investments portfolio
5. ___ Plan for my financial security in retirement
6. ___ Managing a spending plan
7. ___ Reduce my insurance cost and analyze my insurance needs
8. ___ Reduce my taxes and/or increase my income on highly appreciated assets
9. ___ Prepare my estate plan

9. Which three of the above are most important to you at this time? (List in order of importance.)1._______2._______3._______
10. Which investments do you feel most comfortable with?________________________
11. Which investments do you feel least comfortable with?________________________

 

12. What is your current combined gross annual income? (please circle)

Under $50,000 $51,000-$100,000 $101,000-$250,000 $251,000+

13. What is your combined investment net worth, excluding car, home and furnishings? (please circle)

Under $100,000 $101,000-$250,000 $251,000-$1,000,000

$1,001,000-$3,000,000 $3,001,000+

14. What changes do you expect in the future that you wish to plan for?

FamilyObligations: _______________________________________________________ _______________________________________________________________________

Inheritances:_____________________________________________________________

Other: __________________________________________________________________

 

15. What would you like to accomplish through this engagement?____________________

_______________________________________________________________________

_______________________________________________________________________

 

16. Is there anything else we need to talk about? ________________________________

_______________________________________________________________________

_______________________________________________________________________

Please bring this completed questionnaire along with copies of the following with you for your appointment:

Cash Flow Statement (list of income and expenses)

Net Worth Statement (list of assets and liabilities)

Most recent Income Tax Return

Summary of Concerns:_____________________________________________________

Summary of benefits we can provide:_________________________________________

_______________________________________________________________________

_______________________________________________________________________

Next step:_______________________________________________________________