Confidential Questionnaire - Fiscal



Fiscal Fitness, LLC211 E. Verona Ave. Suite 4Verona, WI 53593(608) 848-1133contactus@Confidential QuestionnaireInstructions: You can use Microsoft Word to complete this form. Just tab through the document or click with your mouse and begin typing when you see the black rectangle. To check a box, click it or press the space bar.Date Completed: FORMTEXT ?????Client Name: FORMTEXT ?????Co-Client Name: FORMTEXT ?????Relationship to Co-Client: FORMTEXT ?????Relationship to Client: FORMTEXT ?????Date of Birth: FORMTEXT ????? Date of Birth: FORMTEXT ????? Gender Identity: FORMCHECKBOX F FORMCHECKBOX M FORMCHECKBOX Non-binaryGender Identity: FORMCHECKBOX F FORMCHECKBOX M FORMCHECKBOX Non-binaryAddress: FORMTEXT ????? Address: FORMTEXT ?????City, State, Zip: FORMTEXT ?????City, State, Zip: FORMTEXT ?????Home Phone: FORMTEXT ?????Home Phone: FORMTEXT ?????Other Phone: FORMTEXT ?????Other Phone: FORMTEXT ?????Email: FORMTEXT ?????Email: FORMTEXT ?????Primary person to contact during business hours: FORMTEXT ?????Preferred contact method: FORMCHECKBOX Home Phone FORMCHECKBOX Other Phone or FORMCHECKBOX EmailChildren (or others you support):Name:Relationship:Date of Birth:Dependent:Residence (city & state): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX N FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX N FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX N FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX N FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX N FORMTEXT ????? Financial Planning Priorities and InterestsShort-term goals (next 1-5 years): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Longer-term goals: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What would you like to accomplish with Fiscal Fitness? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What is important to you about your money? For example: charitable involvement, family security, bequests, grandchildren’s education, or anything not listed above. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employment Information, including self employment (if applicable):Client Co-Client Employer: FORMTEXT ?????Employer: FORMTEXT ?????Position: FORMTEXT ?????Position: FORMTEXT ?????Years with this employer: FORMTEXT ?????Years with this employer: FORMTEXT ?????Anticipated employment changes? FORMCHECKBOX Yes FORMCHECKBOX NoAnticipated employment changes? FORMCHECKBOX Yes FORMCHECKBOX NoWhen do you plan to retire? FORMTEXT ?????When do you plan to retire? FORMTEXT ?????Current annual pre-tax salary: $ FORMTEXT ?????Current annual pre-tax salary: $ FORMTEXT ?????Other employment income: $ FORMTEXT ?????Other employment income: $ FORMTEXT ?????Average bonus/commissions: $ FORMTEXT ?????Average bonus/commissions: $ FORMTEXT ?????Total annual income = $ FORMTEXT ?????Total annual income = $ FORMTEXT ?????Is income consistent & reliable? FORMCHECKBOX Yes FORMCHECKBOX NoIs income consistent & reliable? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have non-employment sources of income, such as alimony, pensions, retirement accounts, or rental property? If yes, please describe: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Advisor RelationshipsWhere applicable, rate your current advisor on a scale of 1 (dissatisfied) to 5 (very satisfied)AdvisorRating (1-5)CommentAccountant FORMTEXT ? FORMTEXT ?????Tax Preparer FORMTEXT ? FORMTEXT ?????Attorney FORMTEXT ? FORMTEXT ?????Broker FORMTEXT ? FORMTEXT ?????Insurance Agent (1) FORMTEXT ? FORMTEXT ?????Insurance Agent (2) FORMTEXT ? FORMTEXT ????? FORMTEXT ?????Financial Planner FORMTEXT ? FORMTEXT ?????Tax & Estate Planning InformationWho prepares your tax return? FORMCHECKBOX Self FORMCHECKBOX Paid Preparer Preparer Name: FORMTEXT ?????Client:Which documents do you have?Year drafted?In what state? FORMCHECKBOX Will FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Living Will FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Living Trust FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Durable Power of Attorney (Financial) FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Durable Power of Attorney (Medical) FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Other (e.g. property agreements) FORMTEXT ???? FORMTEXT ?????Co-Client:Which documents do you have?Year drafted?In what state? FORMCHECKBOX Will FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Living Will FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Living Trust FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Durable Power of Attorney (Financial) FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Durable Power of Attorney (Medical) FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX Other (e.g. property agreements) FORMTEXT ???? FORMTEXT ????? Insurance InformationPolicyInsurance companyCoverage Amount?Deductible?Premium?Vehicle 1 FORMTEXT ????? $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Vehicle 2 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Vehicle 3 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Homeowners FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????ClientDo You Have?Employer-Provided?Coverage?Premium?Health: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Disability: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Life: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Umbrella Liability: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Long-Term Care: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????How is your health? FORMTEXT ?????Co-ClientDo You Have?Employer-Provided?Coverage?Premium?Health: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Disability: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Life: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Umbrella Liability: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????Long-Term Care: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No$ FORMTEXT ?????$ FORMTEXT ?????How is your health? FORMTEXT ?????Financial AssetsPlease provide the current value of the following: Account TypeJointClientCo-ClientChecking and savings :$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????CDs + money market funds:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Tax-deferred retirement accounts(IRAs, 401(k)’s, 403(b)’s, etc.):$ n/a$ FORMTEXT ?????$ FORMTEXT ?????Roth IRAs:$ n/a$ FORMTEXT ?????$ FORMTEXT ?????Brokerage accounts:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Mutual funds in taxable accounts:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Education savings (529s, etc.):$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Employee stock purchase plan:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other financial assets:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Do you have a pension? Client FORMCHECKBOX Yes FORMCHECKBOX No Co-Client FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, estimated monthly benefit: Client $ FORMTEXT ?????at age FORMTEXT ??Co-Client $ FORMTEXT ?????at age FORMTEXT ???.How much do you save each month?Retirement plans:$ FORMTEXT ?????Other investment or savings accounts:$ FORMTEXT ?????Do you manage your own investments? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is your desired annual retirement income? (after tax, in today’s dollars) $ FORMTEXT ?????Personal PropertyEstimated Value:Notes:Primary Residence:$ FORMTEXT ????? FORMTEXT ?????Vehicle 1:$ FORMTEXT ????? FORMTEXT ?????Vehicle 2:$ FORMTEXT ????? FORMTEXT ?????Vehicle 3:$ FORMTEXT ????? FORMTEXT ?????Furnishings:$ FORMTEXT ????? FORMTEXT ?????Other:$ FORMTEXT ????? FORMTEXT ?????LiabilitiesCredit Cards: (If not paid in full each month)TypeInterest RateAverage Monthly PaymentCurrent Balance FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ?????Other Debts: Please list mortgage, home equity, auto, personal, business, education, or other loans:TypeTermMaturityDateInterest RateMonthly PaymentCurrent BalanceOriginal Balance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? %$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Have you received a copy of your credit report recently? Client FORMCHECKBOX Yes FORMCHECKBOX No Co-Client FORMCHECKBOX Yes FORMCHECKBOX No If you know your credit score, what is it? Client FORMTEXT ???Co-Client FORMTEXT ???How did you hear about Fiscal Fitness? FORMTEXT ?????OtherOther noteworthy considerations not captured above: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Please email this completed form to:kathy@or mail it to:Fiscal Fitness, LLC211 E. Verona Ave. Suite 4Verona, WI 53593or fax it, attention Kathy:608-268-8671Thank you for the time you have taken to provide this information! ................
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