Client Questionnaire
Client Questionnaire Personal & Confidential
®
Client Information As Of: First Name:
(Salutation):
Last Name:
________________________________
Tax Filing Status:
________________________________
Date of Birth:
_____________________________
Address Line 1:
_____________________________
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)_______ Last Name:
_____________________________
Date of Birth:
_____________________________
Previous Marriage(s)?: _____________________________
SPOUSE/PARTNER BUSINESS INFORMATION Company: ________________________________ Title:
________________________________
Type of Business:
________________________________
Business Address:
________________________________
Citizenship: _____________________________
City: ________________________________
Areas of Interest:
_____________________________
State:
___________Zip________________
Hobbies:
_____________________________
Work Phone:
________________________________
Email:
________________________________
Children Name
Date of Birth
School/Grade
Special Needs/Interests
2
Advisors (Attorney, Accountant, Personal Banker, Stockbroker, Etc.) Advisor Type: ____________________________
Advisor Type:
_______________________________
Name (First Last):
_______________________________
Company:
_______________________________
Company: _______________________________
Address:
_______________________________
Address: _______________________________
City:
_______________________________
City: _______________________________
State:
___________Zip
State: ____________Zip________________
Name (First Last):
_______________________________
Phone:
_______________________________
Fax:
_______________________________
Email:
_______________________________
Advisor Type:
_______________________________
Name (First Last):
_______________________________
Company:
_______________________________
Company: _______________________________
Address:
_______________________________
Address: _______________________________
City:
_______________________________
City: _______________________________
State:
___________Zip
State: ____________ Zip________________
Phone:
_______________________________
Fax: _______________________________ Email:
_______________________________
Advisor Type: ____________________________ Name (First Last):
Phone:
_______________________________
Phone:
_______________________________
_______________________________
Fax:
_______________________________
Fax: _______________________________
Email:
_______________________________
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**
Primary Home
Mortgage Rate
# of Years Left
Ownership H/W.J/TIC*
Address See page 1
Second Home Investment Property Other
* H: Husband W: Wife ** Mortgage and/or Home Equity
J: Joint
TIC: Tenants in Common
3
Personal Property (Art, Jewelry, Cars, Etc.) Description
Ownership H/W/J/TIC*
Current Value
Bank Accounts Cash & Cash Equivalents (Checking, Savings, Cds, T-Bills) Account Type (Checking, Savings, CD, Money Market)
Account Name
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
4
Investments: Private Equity See Attached Statement
Name
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**
See Attached Statement
Current Value
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 Type (UGMA, 529, Trust)
Account Name
See Attached Statement
Current Value
Beneficiary
□ □ □ □ □ □
* H: Husband
W: Wife
J: Joint
TIC: Tenants in Common
5
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
(For any business provide Insurance Documents) * H: Husband W: Wife J: Joint
Business Type
Percent Ownership
Spouse Active?
Children Involved?
Future Plans for Business
TIC: Tenants in Common
6
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 ?)
7
Long Term Care Insurance Insurance Insured Company
Purchase Date
COLA Daily Annual Waiting Benefit Premium Due Policy # Adjustment Benefit Premium Period Period Date (Yes/No?)
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)
8
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
$ 0.00
$ 0.00
9
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
□ Simple Will □ Unified Credit Planning
□ Do you have an Irrevocable Trust?
□ No Will □ Simple Will □ Unified Credit Planning
Current Plan: Gifting 4FMFDU0OF Do you or your spouse plan to gift in the future? Yes No
Comments
Yes No
Would you consider using gifting as a planning tool? If so, expected number of gift recipients: Have you or your spouse ever filed a gift tax return?
YesNo
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 1R
Amount/ year:
Company Match
Yes
No
Does your spouse contribute to a 401(k) plan?
YesNo Amount/ year:
Company Match
Yes
No
10
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
11
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:
12
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
®
Client Information As Of: First Name:
(Salutation):
Last Name:
________________________________
Tax Filing Status:
________________________________
Date of Birth:
_____________________________
Address Line 1:
_____________________________
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)_______ Last Name:
_____________________________
Date of Birth:
_____________________________
Previous Marriage(s)?: _____________________________
SPOUSE/PARTNER BUSINESS INFORMATION Company: ________________________________ Title:
________________________________
Type of Business:
________________________________
Business Address:
________________________________
Citizenship: _____________________________
City: ________________________________
Areas of Interest:
_____________________________
State:
___________Zip________________
Hobbies:
_____________________________
Work Phone:
________________________________
Email:
________________________________
Children Name
Date of Birth
School/Grade
Special Needs/Interests
2
Advisors (Attorney, Accountant, Personal Banker, Stockbroker, Etc.) Advisor Type: ____________________________
Advisor Type:
_______________________________
Name (First Last):
_______________________________
Company:
_______________________________
Company: _______________________________
Address:
_______________________________
Address: _______________________________
City:
_______________________________
City: _______________________________
State:
___________Zip
State: ____________Zip________________
Name (First Last):
_______________________________
Phone:
_______________________________
Fax:
_______________________________
Email:
_______________________________
Advisor Type:
_______________________________
Name (First Last):
_______________________________
Company:
_______________________________
Company: _______________________________
Address:
_______________________________
Address: _______________________________
City:
_______________________________
City: _______________________________
State:
___________Zip
State: ____________ Zip________________
Phone:
_______________________________
Fax: _______________________________ Email:
_______________________________
Advisor Type: ____________________________ Name (First Last):
Phone:
_______________________________
Phone:
_______________________________
_______________________________
Fax:
_______________________________
Fax: _______________________________
Email:
_______________________________
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**
Primary Home
Mortgage Rate
# of Years Left
Ownership H/W.J/TIC*
Address See page 1
Second Home Investment Property Other
* H: Husband W: Wife ** Mortgage and/or Home Equity
J: Joint
TIC: Tenants in Common
3
Personal Property (Art, Jewelry, Cars, Etc.) Description
Ownership H/W/J/TIC*
Current Value
Bank Accounts Cash & Cash Equivalents (Checking, Savings, Cds, T-Bills) Account Type (Checking, Savings, CD, Money Market)
Account Name
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
4
Investments: Private Equity See Attached Statement
Name
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**
See Attached Statement
Current Value
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 Type (UGMA, 529, Trust)
Account Name
See Attached Statement
Current Value
Beneficiary
□ □ □ □ □ □
* H: Husband
W: Wife
J: Joint
TIC: Tenants in Common
5
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
(For any business provide Insurance Documents) * H: Husband W: Wife J: Joint
Business Type
Percent Ownership
Spouse Active?
Children Involved?
Future Plans for Business
TIC: Tenants in Common
6
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 ?)
7
Long Term Care Insurance Insurance Insured Company
Purchase Date
COLA Daily Annual Waiting Benefit Premium Due Policy # Adjustment Benefit Premium Period Period Date (Yes/No?)
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)
8
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
$ 0.00
$ 0.00
9
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
□ Simple Will □ Unified Credit Planning
□ Do you have an Irrevocable Trust?
□ No Will □ Simple Will □ Unified Credit Planning
Current Plan: Gifting 4FMFDU0OF Do you or your spouse plan to gift in the future? Yes No
Comments
Yes No
Would you consider using gifting as a planning tool? If so, expected number of gift recipients: Have you or your spouse ever filed a gift tax return?
YesNo
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 1R
Amount/ year:
Company Match
Yes
No
Does your spouse contribute to a 401(k) plan?
YesNo Amount/ year:
Company Match
Yes
No
10
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
11
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:
12
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
