Financial Planning

Questionnaire

To complete this form by hand:

Print all pages of this form and bring the completed form to our meeting.

To complete this form electronically:

• Visit www.StrategicPoint.com/Forms and save the writable PDF to your computer, then open it using Adobe’s Acrobat Reader.
• Complete the form by typing into the designated fields and/or checking the appropriate buttons. Tip: you can tab from field to field.
• When finished, save the form and email it to [email protected]. Or you can bring a copy with you to our meeting.

GENERAL INFORMATION
YOUR First & Last Name: Today’s Date: / /

Marital Status:  Single  Married  Partner  Separated  Divorced  Widowed

Street Address:

City: State: Zip Code:

Home Phone: ( ) – Email:

Your Date of Birth: / / Are You a U.S. Citizen?  Yes  No

SPOUSE’S/PARTNER’S (CO-CLIENT’S) First & Last Name:

Spouse’s/Partner’s Date of Birth: / / Is your Spouse/Partner a U.S. Citizen?  Yes  No

Spouse’s/Partner’s Email:

EMPLOYMENT INFORMATION
YOUR Employment:  Self-Employed  Company Owner  Employee  Retired
Company Name:

Occupation: Years with Company:

Street Address:

City: State: Zip Code:

Work Phone: ( ) – Ext: Fax: ( ) –

Work Email:

SPOUSE’S/PARTNER’S Employment:  Self-Employed  Company Owner  Employee  Retired

Company Name:

Occupation: Years with Company:

Street Address:

City: State: Zip Code:

Work Phone: ( ) – Ext: Fax: ( ) –

Work Email:

FORM CONTINUES ➤

Questions? Please call (401) 273-1500. 1

Financial Planning Questionnaire (continued)

ASSETS
Bank Accounts
Type of Account Owner Balance

Checking $

Money Market / Savings $

All CDs $

Other: $

How much of the above amount do you want earmarked for retirement? $

Retirement Accounts
List tax-deferred accounts separately and include accounts labeled: 401(k), 403(b), 457, ESOP, SEP, SIMPLE, Profit Sharing,
TSA, Annuities, Traditional IRA and Roth IRA. Please attach copies of most recent statements.

Name of Account At Owner Balance

Example: Lifespan 403(b) Fidelity Mary $42,000

$
$

Taxable Accounts
List accounts separately and include: brokerage accounts, joint accounts, trusts, TODs, PODs, non-qualified
annuities and accounts in an individual name. Please attach copies of most recent statements.

Name of Account At Owner Balance

Example: Individual Account Vanguard John $51,000

FORM CONTINUES ➤

Questions? Please call (401) 273-1500. 2

Financial Planning Questionnaire (continued)

Business Ownership
Include businesses in which you have direct ownership.

Name of Business Owner Business Type Appraisal (your share)

Example: Peter’s Painting Co. Peter S-Corp $250,000

Do you plan to sell your business to create retirement assets?  Yes  No

If yes, in what approximate year?

Assumed annual growth rate of business: (If left blank, we will grow your business by 8% until sold.) %

Personal Property
Include collectibles, boats, automobiles, etc.

Property Owner Value

Example: Art Collection Mary/John $75,000

Real Estate
For additional properties, please attach a separate sheet.

Property Investment or Personal Owner Value

Example: 212 Windham Personal Residence Joint $315,000

Personal Residence $

Second Home $

Investment Property (1) $

Investment Property (2) $

Other: $

How much pre-tax income do you receive each year from your investment properties? $

Which of these real estate properties is available to be sold with the proceeds used for retirement?

In what year would you like to sell the property?

Children and Other Dependents

Please list names, dates of birth, and relation for children, grandchildren, or any other dependents.

Name Date of Birth Relation

Example: Julia 2/23/2001 Daughter

FORM CONTINUES ➤
Questions? Please call (401) 273-1500. 3
Financial Planning Questionnaire (continued)

Assets Held for Education

List separately for each child or grandchild and include 529 Plans, Coverdell IRAs, Custodial Accounts,
Education Savings Bonds, Mutual Fund Accounts, etc.

Name of Account Type Owner Beneficiary Balance

Example: CollegeBoundFund 529 Plan Mary Julia $15,000

FUNDING NEEDS FOR CHILDREN AND OTHER DEPENDENTS

We will use the college savings information from the Assets section to determine our education funding projections.

Name Date of Birth College Start Year Years to Fund

Example: Julia 2/23/2001 September 2013 4 years

Annual Cost
What is the annual cost of college you are willing to fund for each child?
Keep in mind that your children may get financial aid or choose to take out student loans to help pay for
expenses. Therefore, list only the amount you are willing to pay in current dollars. For instance, if you
expect a year of college (graduate school) to cost $15,000 and you plan to pay two-thirds of that amount,
then you would give “$10,000” as your estimated cost. $

Annual expenses for other dependents (for example, parents): $

LIABILITIES
Mortgages
Primary Residence

Start Date: / / Original Amount: $ Balance Remaining: $

Term: Interest Rate: % Property Taxes: $ Insurance: $

Second Home

Start Date: / / Original Amount: $ Balance Remaining: $

Term: Interest Rate: % Property Taxes: $ Insurance: $

Investment Property

Start Date: / / Original Amount: $ Balance Remaining: $

Term: Interest Rate: % Property Taxes: $ Insurance: $

FORM CONTINUES ➤

Questions? Please call (401) 273-1500. 4

Financial Planning Questionnaire (continued)

Other

Start Date: / / Original Amount: $ Balance Remaining: $

Term: Interest Rate: % Property Taxes: $ Insurance: $

Home Equity Line of Credit Balance: $

Amount Available: $

Other Debt
Debt Balance Interest Rate(s)

Vehicle $ %

Vehicle $ %

All Credit Cards $ %

Student Loans $ %

Other: $ %

INCOME AND RETIREMENT ANALYSIS

YOUR Current Annual Income? $

At what age do YOU expect to retire? (If you are already retired, put in your current age.)
(We will use this age to run your retirement projections.)

How much do you contribute to YOUR retirement plans each year? $

Is there an Employer match?  Yes  No

Amount ($ or %) matched by Employer? $ %

SPOUSE’S/PARTNER’S Current Annual Income? $

At what age does your SPOUSE/PARTNER expect to retire?

(If she/he has already retired, put in her/his current age.)

How much does your SPOUSE/PARTNER contribute to her/his retirement plans each year? $

Is there an Employer match?  Yes  No

Amount ($ or %) matched by Employer? $ %

How much will you need to spend each month in retirement?

(Include taxes and think in terms of today’s dollars.)
(If you leave this question blank, we will assume you will need 85% of your current income.) $

Additional Annual Savings: $

Type of Account:

FORM CONTINUES ➤

Questions? Please call (401) 273-1500. 5

Financial Planning Questionnaire (continued)

Pensions
Client Name Monthly Amount at Start Age at Start Inflation COLA

Example: Mary $1,200 65 l Yes  No

$  Yes  No
$  Yes  No
$  Yes  No

What payout option does this pension represent? (We will assume joint and 50% survivor unless otherwise indicated.)

 Single Life Name Applicable Pension(s):

 Joint and 50% Survivor Name Applicable Pension(s):

 Joint and 100% Survivor Name Applicable Pension(s):

Social Security
Current Payment Payment Amount Payment Amount at Payment Amount
Client Name Amount (if applicable) at age 62 Full Retirement Age at age 70

Example: John $1,474 $2,057 $2,822

$ $ $ $

$ $ $ $

OTHER INCOME AND EXPENSES

Do YOU expect to work part-time during retirement?  Yes  No
If yes, for how many years? At what salary (in current dollars)? $

Does your SPOUSE/PARTNER expect to work part-time during retirement?  Yes  No

If yes, for how many years? At what salary (in current dollars)? $

What is the value of any expected inheritance/gifts? $

In what year would you estimate that you might receive this inheritance?

What is the value of any anticipated expenses or major purchases (other than education)? $

In what year should these expenses be applied?

Is there anything else we should know about when we plan for your retirement?

FORM CONTINUES ➤

Questions? Please call (401) 273-1500. 6

Financial Planning Questionnaire (continued)

INSURANCE ANALYSIS

For how many years will you need life insurance?

If you leave blank, we will assume until the first year of retirement.

Life Insurance: Term Policies

Please attach your latest statement.

Face Value Insured Group or Individual Term Remaining Premium per Year

Example: $500,000 John Individual 10 years $700

$ $

$ $

$ $

$ $

Life Insurance: Permanent Policies

Please attach your latest statement.

Year Premium
Face Value Type Purchased Insured Cash Value per Year

Example: $100,000 Whole Life 1998 Mary $10,000 $1,000

$ $ $

$ $ $

$ $ $

$ $ $

Long Term Disability Insurance

Please attach policies if available.

Name Monthly Benefit Group or Individual Premium per Year

Example: John $3,000 Individual $2,100

$ $

$ $

$ $

$ $

Long Term Care Insurance

Please attach policies if available.

Name Daily Benefit Inflation Rider Term Premium per Year

Example: Mary $150 l Yes  No 3 years $1,500

$  Yes  No years $

$  Yes  No years $

FORM CONTINUES ➤

Questions? Please call (401) 273-1500. 7

Financial Planning Questionnaire (continued)

ESTATE PLANNING
Do you have updated wills?  Yes  No
Do you have powers of attorney?  Yes  No
Have you executed health care proxies?  Yes  No
When were these documents last updated?

Have you established any trusts?  Yes  No

If yes, names of trust(s) you have established:

1) 2)

3) 4)

General Notes

Whom may we thank for referring you?

Please bring your completed Financial Planning Questionnaire along with any appropriate supporting
documents to the meeting with your StrategicPoint advisor.

Please DO NOT complete this section PRIOR to meeting with your advisor.
I acknowledge receipt of StrategicPoint Investment Advisor’s Privacy Policy, Form ADV Part 2,
Proxy Voting Policy and the BCP disclosure statement.

✘
Client Signature

Print Name

Questions? Please call (401) 273-1500. 8