Personal Wealth Questionnaire

My Profile

All information gathered to complete your personalized financial plan will be held in the strictest confidence. Information will not be disclosed or used for any other purpose. A copy of Integrity Financial’s Privacy Policy is available upon request.

  • Spouse's Information

  • Dependent Children

  • Income Planning

  • Please check the box below if true and leave the box blank if not.
  • Income Information

  • Please list income you may receive from other sources (rental properties, annuities, investment grade life insurance, and social security) as well as how much from each.
  • If you have a pension plan, please list your monthly pension at retirement, what age your benefits begins, what the survivor benefits are ($), and whether the benefits are indexed for inflation.
  • Please estimate how much your fixed and variable monthly expenses are.
  • Asset Management

  • Please check the box below if true and leave the box blank if not.
  • Please list below all retirement assets you currently possess (i.e. 401(k), IRA, Roth IRA, SEP IRA, Annuities). For each one, please mention the account name, current balance, and annual contribution. If your 401(k) plan includes a matching contribution, please describe it.
  • If you own a business, please write down the company name, % ownership, estiated current value, and entity type.
  • Please write down all liquid accounts you currently own (i.e. Checking, Savings, Money Market, CD’s). For each one, please mention the account name, current balance, and annual contribution.
  • Tax Diversification

  • Please check the box below if true and leave the box blank if not.
  • Please write your pre-aax Savings, roth savings, current or expected AGI, and current tax rate.
  • Risk Management

  • Please check the box below if true and leave the box blank if not.
  • Please write down life insurance policies that are you a part of (i.e. Personal, Employer's, Disability Income, Long Term Care, Umbrella). For each one, please mention the name of the insured, insurance company, type of coverage, coverage amount, monthly premium, and year issued.
  • Credit Management

  • Please check the box below if true and leave the box blank if not.
  • Please write down whether you have a mortgage, second mortgage, or HELOC. For each one, please write down the mortgage balance, monthly payment, interest rate, loan origination date, mortgage term.
  • Please write down whether you have a mortgage, second mortgage, or HELOC. For each one, please write down the mortgage balance, monthly payment, interest rate, loan origination date, mortgage term.
  • Please write down any other liabilities you may have (i.e. loans, major credit cards, etc.). For each one, please write down the liability type, amount owed, monthly payment, and interest rate.
  • Legacy Planning

  • Please check the box below if true and leave the box blank if not.
  • Charitable Giving

  • Please check the box below if true and leave the box blank if not.