Investment Objectives Questionnaire

Personal and Family Information

A. Name__________________________

SSN_______-_______-_________

Date of Birth _______________________

B. Spouse's Name ___________________

SSN_______-_______-_________

Date of Birth _______________________

C. Address____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

D. Telephone Numbers

(        )____-__________(Work)

(      )____-__________(Cell)

(        )____-__________(Home)

(      )____-__________(Pager)

E.  Email Address

F. Children and Grandchildren

Dependent?

Name

Age

Yes

No

_______________________________________________________________

_________

_______

______

______________________________________________________________

_________

_______

______

_______________________________________________________________

_________

_______

______

_______________________________________________________________

_________

_______

______

_______________________________________________________________

_________

_______

______

_______________________________________________________________

_________

_______

______

_______________________________________________________________

_________

_______

______

_______________________________________________________________

_________

_______

______

G.  Current Employment

Employer

Position

Years Employed

You ___________________________

___________________________________

___________

Spouse ________________________

___________________________________

___________

Personal Financial Profile

Note:  Copies of brokerage statements, bank statements and other documents can be submitted in place of the following financial information

Description

Type of Ownership

Value

Cash and Cash Equivalents:

Checking Account ___________________________
                                           (Bank)

___________________________

$_______________

Checking Account ___________________________
                                           (Bank)

_________________________

$_______________

Savings Account ____________________________
                                            (Bank)

___________________________

$_______________

Savings Account ____________________________
                                            (Bank)

_________________________

$_______________

Money Market Funds

__________________________

$_______________

_________________________________________

__________________________

$_______________

_________________________________________

__________________________

$_______________

_________________________________________

__________________________

$_______________

Investments:

Stocks

Company Name

Where Held

Shares

__________________________

_______________________

_____________

________

$______

__________________________

_______________________

_____________

________

$______

__________________________

_______________________

_____________

________

$______

__________________________

_______________________

_____________

________

$______

__________________________

_______________________

_____________

________

$______

__________________________

_______________________

_____________

________

$______

Mutual Funds

Fund Name

Where Held

Shares

__________________________

________________________

_____________

________

$______

__________________________

________________________

_____________

________

$______

__________________________

________________________

_____________

________

$______

__________________________

________________________

_____________

________

$______

__________________________

________________________

_____________

________

$______

Bonds

Description of Issue

Where Held

__________________________

________________________

_____________

$_______

__________________________

________________________

_____________

$_______

__________________________

________________________

_____________

$_______

__________________________

________________________

_____________

$_______

__________________________

________________________

_____________

$_______

Retirement Funds

Beneficiary

Value

% Vested

Company plans

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

IRAs

________________________________________

_______________

$_______________

________________________________________

_______________

$_______________

Keoghs

________________________________________

_______________

$_______________

________________________________________

_______________

$_______________

Other:

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

Total Portfolio Value:

$_______________

Personal Assets:

Residence

_______________

$_______________

Autos

_______________

$_______________

Jewelry

_______________

$_______________

Collectibles

_______________

$_______________

Personal Property

_______________

$_______________

________________________________________

_______________

$_______________

________________________________________

_______________

$_______________

Other Information

Marginal income tax bracket (federal and state)

__________%

Total annual income (gross) per 1040

$___________

Annual living expense (housing, food, taxes, etc)

$__________

Annual discretionary expenses (entertainment, vacation, etc.)

$___________

Annual amount invested or saved (including contributions to retirement plans)

$___________

Outstanding Stock Options

Company Name

Shares

Option Price

Date Excisable

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

________________________________________

_______________

$_______________

____________

Goal Setting Worksheet

On a scale of 1-5, how important to you is each of the following goals or objectives?

High

Medium

Low

Maintain present standard of living

5

4

3

2

1

Improve standard of living

5

4

3

2

1

College education for children

5

4

3

2

1

College education for grandchildren

5

4

3

2

1

Supporting adult children

5

4

3

2

1

Distributing wealth to heirs

5

4

3

2

1

Supporting parents or parents-in-law

5

4

3

2

1

Supporting surviving spouse

5

4

3

2

1

Supporting charitable causes

5

4

3

2

1

Transfer control of business to others

5

4

3

2

1

Transfer ownership of business to others

5

4

3

2

1

Investing regularly

5

4

3

2

1

New car

5

4

3

2

1

Vacation home

5

4

3

2

1

Extraordinary travel

5

4

3

2

1

Children's weddings

5

4

3

2

1

Other_______________________

5

4

3

2

1

____________________________

5

4

3

2

1

____________________________

5

4

3

2

1

1.  How much do you need to live upon retirement in today's after-tax dollars?

$______________per month

2.  If the spouse providing primary family support were disabled for a long period, what would the family's expenses be in today's after tax dollars?

$______________per month

3.  If the spouse providing primary support died today, what would the family's expenses be in today's after-tax dollars (excluding children's college expenses)?

$______________per month

4.  At what age would you like to retire?_________    Spouse?_________

5.  What educational expenses do you expect to provide for your children or grandchildren?

Child or Grandchild

Amount per Year

Number of Years

Starting Year

_____________________________________________

$______________

______________

___________

_____________________________________________

$______________

_______________

___________

_____________________________________________

$______________

_______________

___________

_____________________________________________

$______________

_______________

___________

_____________________________________________

$______________

_______________

___________

_____________________________________________

$______________

_______________

___________

_____________________________________________

$______________

_______________

___________

6.  What assumptions are reasonable for your projections?

This Year

Future Years

Salary

$______________

+____________%

Bonus

$______________

+____________%

Retirement plan contributions

$______________

+____________%

Retirement plan earnings

$______________

+____________%

7.  What inflation rate is reasonable for your projections?

Short term (two to five years)

__________%

Long term (more than five years)

__________%

Completed by:

_____________________________________________
Signature

___________________________________________ __________
Date

_____________________________________________
Signature

___________________________________________ __________
Date