Pre-Appointment Form We are looking forward to getting together with you. If you have any questions or require special assistance prior to your visit, please call our office at 832.559.8777. Step 1 of 13 7% The following items would be helpful to have at the time of our visit:1. All brokerage firm statements 2. All life insurance & annuity policies 3. All IRA & retirement statements 4. 2 Years of Tax Returns 5. Social Security Statement (SSA.gov)CONTACT INFORMATIONName First Last NicknameDate of Birth MM slash DD slash YYYY Working At/Retired From:Current/Former Occupation:Retired?YesNoSemiSpouse Name First Last Spouse NicknameSpouse Date of Birth MM slash DD slash YYYY Spouse Working At/Retired From:Spouse Current/Former Occupation:Spouse Retired?YesNoSemiHome Phone:Cell Phone:Email Address: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Were you referred to us?NoYesIf so, by whom? FAMILYNumber of ChildrenNumber of GrandchildrenDo any of your children or grandchildren have special needs?NoYesAre any of your children or grandchildren listed as joint owners on any of your accounts/assets?NoYesFamily Notes: LEGAL ITEMSWhich of the following legal documents do you have in place?WillYesNoPower of Attorney (POA) AssetsYesNoPower of Attorney (POA) HealthYesNoLiving WillYesNoLiving TrustYesNo LEGAL ITEMSWhich of the following do you have in place?Umbrella PolicyYesNoLong Term Care InsuranceYesNoDeath Benefit Life InsuranceWholeTermUniversalLife InsuranceWholeTermUniversal CASH FLOWPlease list monthly income from each source.PensionYouYour Spouse(Survivor Options)YouYour SpouseSocial SecurityYouYour SpouseWagesYouYour SpouseOther IncomeYouSource(s)TotalOther IncomeSpouseSource(s)TotalAre these amounts net or gross?NetGrossHow much are your monthly expenses? Here are some common expenses: Mortgage, Food, Gas, Car Loan, Insurance, Utilities, Gifts/Donations, Medical, Taxes, Social Security, etcTotal CASH FLOWIs your current cash flow sufficient and comfortable?YesNoDo you live off interest your investment dollars earn?YesNoDo you anticipate any significant changes in cash flow?YesNoAre you planning any major lifestyle changes?YesNoDo you foresee any large purchases greater than $5,000 within the next 3 years?YesNoDo you contribute to charity?YesNo LIFE EVENTSIn the near future I expect to: (Please check all that apply) Buy a home Sell a home Improve a home Retire Care for a parent Start/Expand a business Pay off debt Start a part-time job Help fund education costs for a family member Sell a property Receive an inheritance Purchase a property Other ASSETSPlease check off the accounts you currently hold and list the total amount in the box provided, and bring the latest statement in for your visit (Optional). Bank / Credit Union Accounts $ Mutual Funds / Stocks / Bonds $ Brokerage Accounts $ Retirement Accounts from Work $ CDs $ Business Interest $ Annuities $ IRAs / 401K / 401B / Keoghs / TSAs $ Life Insurance $ Long Term Care Insurance $ Promissory Notes / Contract for Deed $ Other Assets $ ASSETSProperty:Home Value $Autos and Personal Property $Rental/Additional Properties $ ASSETSDescriptionBalance OwedPay Off Date MM slash DD slash YYYY DescriptionBalance OwedPay Off Date MM slash DD slash YYYY DescriptionBalance OwedPay Off Date MM slash DD slash YYYY Additional InformationIf you are not already retired, when do you want to retire?How did you acquire your wealth?How involved would you like to be with your investments?What is most important about your money to you?Are you more concerned about growing your assets or protecting what you already have? ConcernsWhich of the following are your top three concerns? Losing too much money in the stock market Avoid paying too much in taxes Considering retirement and not sure if I/we can afford to Not having a reliable income plan for retirement Concerned about giving away life savings due to a catastrophic illness Outliving nest egg Uncertainty about stock market Leaving a legacy to children and/or grandchildren Need direction with 401K and/or IRA accounts ObjectivesWhich of the following describes your risk tolerance when it comes to retirement assets?ConservativeModerateAggressiveWhat are your Financial Objectives? (Check all that apply) Income Now Tax-Deferred Growth Guarantees Provided Pass Assets to Beneficiaries Growth Potential Other By submitting your contact information, you consent to be contacted regarding retirement income strategies that utilize investments and insurance products.NameThis field is for validation purposes and should be left unchanged. Δ
