Confidential Questionnaire
Retirement +
Thank you for your interest in working with the Retirement + system. The information you provide on this questionnaire is confidential and is used only to help facilitate the complimentary introductory visit.
The introductory visit gives us the opportunity to learn more about you, your financial planning needs, your questions and concerns, and how you would like to work with a trusted advisor. We also want this meeting to provide you with an opportunity to learn about us; what we do, how we work, and the potential benefits of choosing the Retirement + system. We will answer any questions you may have about our services, our fee structure, and what the experience of working with us will be like. This meeting will help both of us determine whether there is a good fit between your needs and our services.
The Retirement + system was founded on the principle that our clients’ interests always come first. Building on this tradition, we are proud to be at the forefront of the pioneering trend of integrating life planning with financial planning. Because of the unpredictability of life and the complexity of financial markets, it is essential to work with a financial advisor who can help you achieve your financial goals. In addition, it is important to select an advisor who truly cares about what is most important to you and understands your needs and values.
This questionnaire includes two sections: a brief summary of personal data, and a Financial Satisfaction Survey. Both sections are quick and easy to complete and will provide us with a snapshot of your unique situation as well as the level of satisfaction with components of your financial life.
This questionnaire is completely voluntary and if you can’t complete it we would still love to meet with you at our introductory visit. Do not worry about getting exact numbers, “ballpark” estimates will work great and allow us to identify any areas of your finances we may be able to assist you.
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Personal Information
Name
First Name
Last Name
Your Date of Birth
-
Month
-
Day
Year
Date
Do you have a spouse or significant other?
Yes
No
Spouse/partner's Name
First Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Spouse's Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Spouse's Phone Number
-
Area Code
Phone Number
Preferred Method of Communication
EMAIL
Phone
Text
Any children?If so, what are their names and ages?
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Employment Status
Your occupation
Your employer
Current monthly income (net)
What age are you planning to retire? Or date you retired?
Other employment information:
spouse's occupation
Spouse's Employer
Spouse's Monthly income (net)
What age is your spouse planning to retire? Or date he/she retired?
Spouse's other employment information:
Will you or your spouse receive a pension in retirement?
Yes - just me
Yes - just my spouse
Yes - both of us will
No - neither of us
Please list your expected pension amount(s) and if there are any survivor benefits below:
Please check if you have
Attorney
Insurance Agent
Accountant
Stock Broker/Financial Advisor
Please Check if you have
Will
Durable Power of Attorney
Health Care Power of Attorney
Living Will
Living Trust
Irrevocable Trust
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Assets & Liabilities
Assets
Total Amounts
Checking, Money Market, CDs
Taxable Brokerage Accounts
Stock Options
Restricted Options
Deferred Compensation Plan
Employer Retirement Accounts (401k, 403b, 457, ESOP, etc.)
Personal Retirement Accounts (IRAs, Roths, SEP, SIMPLE)
College Accounts (GET Units, 529 plans, etc.)
Personal Residence
Vacation Property
Investment Real Estate
Total Assets
Liabilities
Total Amounts
Primary Mortgage
Other Mortgage
Home Equity Loan
Credit Card Balances
Education Loans
Auto Loans
Business Loans
Personal Loans
Other Personal Debt
Other Liabilities
Home Equity Line of Credit
Total liabilities
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Health & Social Security
How's your overall health?
Very Healthy
Pretty Healthy
Somewhat Healthy
Not Very Healthy
How's your spouse's overall health?
Very Healthy
Pretty Healthy
Somewhat Healthy
Not Very Healthy
Not applicable
Which of the following do you currently have?
Insurance
Medicare
Medicaid
Life Insurance Policy
Long Term Care Plan
Which of the following does your spouse currently have?
Insurance
Medicare
Medicaid
Life Insurance Policy
Long Term Care Plan
Social Security Questions
You
Spouse/Partner
Anticipated age of collection of Social Security
Anticipated monthly amount
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Retirement Planning
In retirement, what is your ideal monthly income amount?
During retirement, do you plan on...
maintaining your current lifestyle
downsizing to minimize expenses
increasing your current lifestyle to account for vacations, major purchases, etc.
In order of importance, what are your three most critical financial issues?
Do you have any specific questions you would like Shon Peil and his team at Retirement Plus to answer in your next visit?
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Financial Satisfaction Survey
Directions: The statements below will help you to think about and assess how satisfied you are with many aspects of your financial life. Select and record your level of satisfaction for each statement.
I am satisfied...
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
...with my ability to meet my financial obligations.
...with the income my current job or career provides me.
...with my spending habits.
...with the level of debt I carry.
...with the “extras” that I am able to buy for myself and/or others.
...with the level and quality of insurance protection I currently have.
...with the amount of money that I save and invest on a regular basis.
...with my current investment choices.
...that I am on track to build a sufficient retirement nest egg.
...with the level of employee benefits I receive.
...with my style of personal bookkeeping and financial record management.
...with my ability to provide financial help to family members.
...with my estate plan.
...with my level of charitable giving.
...with the level of financial education I have attained.
...with how I respond emotionally to my personal finance issues.
...with my ability to communicate about my financial matters.
...with the feelings I have about my money life.
...that financial issues do not cause stress or strain in the relationships that are important to me.
...with the working relationships I have with my financial service providers (i.e., insurance agent, banker, broker, financial planner, accountant).
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