Integrity FinancialPersonal Wealth Questionnaire

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.

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?

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