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.

Advisor*
Name*
First Last
Birthdate
Email*
Home Address
Phone
Spouse's Information
Name
First Last
Birthdate
Email
Phone
Home Address
Dependent Children
Names
Birthdays/Ages
Grandchildren's' Names
Grandchildren's' Ages
Income Planning
Income Planning Questionnaire
Please check the box below if true and leave the box blank if not.
- I have automatic deposits into an investment account either per payroll or on a monthly basis.
- I have a liquid emergency fund equal to 3-6 months of current monthly expenses.
- I have developed a household budget.
- I actively track and monitor my monthly expenses.
- I have calculated the amount of assets needed to cover my monthly expenses through retirement.
Income Information
Age you would like to Retire:
Monthly retirement income goal (gross):
Gross income per paycheck (You):
# of Paychecks per year
Expected % raise per year:
Gross income per paycheck (Spouse):
# of Paychecks per year (Spouse):
Expected % raise per year:
Other Income
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.
Pension Plan
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.
Monthly Expenses
Please estimate how much your fixed and variable monthly expenses are.
Asset Management
Asset Management Questionnaire
Please check the box below if true and leave the box blank if not.
- I am confident that my investments are appropriate to meet my long-term goals.
- My various investment accounts working together consistently toward a holistic vision.
- In the last year, I have prepared a personal balance sheet that articulates my assets and liabilities.
- I actively review my monthly bank and investment statements.
- I have calculated the amount of assets needed to meet my monthly retirement income goals.
Asset Information
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.
Business Ownership / Interest
If you own a business, please write down the company name, % ownership, estiated current value, and entity type.
Liquid Accounts
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
Tax Diversification Questionnaire
Please check the box below if true and leave the box blank if not.
- I have investments in a Roth 401(k) or Roth IRA.
- I have an investment grade life insurance policy.
- My professional advising team has estimated my projected estate tax liability.
How many times during the year do you meet with your CPA?
Do you feel your meetings are forward-looking or reactive?
Current Tax Classifications:
Please write your pre-aax Savings, roth savings, current or expected AGI, and current tax rate.
Risk Management
Risk Management Questionnaire
Please check the box below if true and leave the box blank if not.
- I have a policy that would provide monthly income if I were disabled.
- I have health insurance through my company.
- I have undergone a life insurance needs analysis in the last year.
- I have reviewed my current life insurance policy with your agent in the last year.
- My life insurance policies cover chronic or critical illness.
- I have explored different solutions to cover potential long-term care costs.
- I have an umbrella policy.
- I have reviewed my umbrella and liability insurance limits in the last year.
- I have reviewed my homeowner’s policy in the last year.
Life Insurance
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
Credit Management Questionnaire
Please check the box below if true and leave the box blank if not.
- I have borrowed money to finance a home.
- I have a home equity line of credit.
- I have borrowed money to finance an investment property.
- I have borrowed money for a small business enterprise.
- I have you borrowed money to finance higher education or professional development.
- I pay off my consumer debt in full every month.
- I reviewed my credit report in the last two years.
Current Market Value of Primary Residence:
Mortgage Information of Primary Residence:
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.
Current Market Value of Other Real Estate Properties:
Mortgage Information of Other Real Estate Properties:
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.
Other Liabilities:
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
Legacy Planning Questionnaire
Please check the box below if true and leave the box blank if not.
- I have reviewed my will and/or trust documents in the last five years.
- I have reviewed/updated my beneficiaries in the last two years.
- My estate plan includes clearly-defined incapacity documents.
- My legal team prepared a visual overview of my trusts/estate.
- As a business owner, I have had my business valued/appraised in the last three years.
- As a business owner, I have a buy/sell agreement or a written exit plan in place.
- I have considered a GRAT to freeze the value of my business.
- I exercise an annual gifting plan to reduce my taxable estate and take advantage of the current annual gift exemption.
- I have considered a family LLC/LLP for discounting my estate and minimizing tax consequences.
- I have utilized a 529 college savings plan for estate tax purposes.
- I have life insurance policies held inside an irrevocable life insurance trust.
- I have a retirement savings/investment plan for each of my children and/or grandchildren.
- I have a special needs trust in place for if any of my If any of my children are disabled or on the autism spectrum.
- I have set up life insurance policies for my children and/or grandchildren.
Charitable Giving
Charity Questionnaire
Please check the box below if true and leave the box blank if not.
- I feel that my charitable giving is focused and intentional.
- I have used a Donor Advised Fund to streamline the tax reporting of your grants.
- I have set up a family foundation, and if I have not, the idea interests me.
- In the last year, I have had a meaningful conversation with my children about charitable
- I have causes that are important to me.
Which charitable causes or organizations are most meaningful to you?
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Personal Wealth Questionnaire

My Profile

Spouse's Information

Dependent Children

Income Planning

Income Information

Asset Management

Tax Diversification

Risk Management

Credit Management

Legacy Planning

Charitable Giving