Please complete prior to first meeting
No information is collected until pressing Submit below.
Contact Information
First Name:
Last Name:
Nickname:
Date of Birth:
Current/Former Occupation:
Working At/ Retired From:
Retired:
Yes
No
Semi
Spouse Information
Spouse Full Name:
Nickname:
Date of Birth:
Current/ Fomer Occupation:
Working At/ Retired From:
Spouse Retired:
Yes
No
Semi
Primary Address
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Spouse Cell Phone:
Business Phone:
Spouse Business Phone:
Email:
Spouse Email:
What is your preferred method of communication?
Email
Phone
Both Mail & Phone
Are you currently working with another advisor?
Yes
No
Family
List Children's Names
1. Child Name & Age:
Number of children they have:
Please select one
1
2
3
4
5
More than 5
2. Child Name & Age:
Number of children they have:
Please select one
1
2
3
4
5
More than 5
3. Child Name & Age:
Number of children they have:
Please select one
1
2
3
4
5
More than 5
4. Child Name & Age:
Number of children they have:
Please select one
1
2
3
4
5
More than 5
Do any of your children or grandchildren have special needs?
Yes
No
Are any of your children or grandchildren listed as joint owners
Yes
No
Legal Items
For PCs, hold down Ctrl for multiple answers. For Ipad or mobile devices, checkmark for multiple answers.
Which of the following legal documents do you have in place?
Will
Power of Attorney (POA) Assets
Power of Attorney (POA) Health
Living Will
Trust
Additional Items
Which of the following do you have in place?
Umbrella Policy
Long Term Care Insurance
Life Insurance?
Yes
No
Type:
Please select one
Whole
Term
Universal
Please list monthly income from each source.
Husband
Social Security:
Pension:
Wages:
Other Income:
Wife
Social Security:
Pension:
Wages:
Other Income:
Are these amounts:
Please select one
Before taxes are taken.
Net after taxes.
Here are some common expenses:
Mortgage, Food, Gas, Car, Loan, Insurance, Utilities, Gifts/Donations, Medical, Taxes, Social Security, etc.
Is your current cash flow sufficient and comfortable?
Yes
No
Don't Know
Do you live off interest your investment dollars earn?
Yes
No
Don't Know
Do you anticipate any significant changes in cash flow?
Yes
No
Don't Know
Are you planning any major lifestyle changes?
Yes
No
Don't Know
Do you forsee any purchases more than $5000 in the next 3 years?
Yes
No
Don't Know
Do you contribute to charity?
Yes
No
Don't Know
Life Events
For PCs, hold down Ctrl for multiple answers. For Ipad or mobile devices, checkmark for multiple answers.
In 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 a debt
Start a part-time job
Help fund education costs for a grandchild
Sell a property
Receive an inheritance
Purchase a property
Other plans for the near future:
Assets
For PCs, hold down Ctrl for multiple answers. For Ipad or mobile devices, checkmark for multiple answers.
Please check off the accounts you currently hold:
Bank/ Credit Union accounts
Mutual funds/ Stocks/ Bonds
Brokerage accounts
Retirement accounts from work
C.D.s
Business interest
Annuities
IRAs/ 401k/ Keoghs/ TSAs
Life insurance
Long term care insurance
Promissory notes/ Contract for deed
Other Accounts:
Total Value Of All Acounts:
Please select one
Less than $300k
$300k - $500k
$500k - $1 Million
$1 Million - $1.5 Million
More than $1.5 Million
Liability:
Balance Owed:
Properties
Home Value:
Mortgage Balance:
Auto(s) & Personal Property:
Rentals/ Additional Properties:
Rental Mortgage Balance:
Additional Information
If you are not already retired, when do you want to retire?
How did you aquire your wealth?
How involved do you like to be with you investments?
What is most important about your money?
If something were to happen to you tomorrow,
Who do you want taken care of?
Are you more concerned about growing your assets
or protecting what you already have?
Concerns
For PCs, hold down Ctrl for multiple answers. For Ipad or mobile devices, checkmark for multiple answers.
Which of the following are your top three concerns?
Losing too much money in the stock market.
Avoid paying too much taxes.
Considering retirement and not sure if we/I 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.
Not sure about our current advisor relationship.
On a scale from 1 to 10 (10 being most likely) How likely would you be to take firm and make change if Mark Kennedy could help you solve these concerns?
Please select one
1
2
3
4
5
6
7
8
9
10
Financial Objectives
How would you describe your investment knowledge?
None
Average
Limited
Good
High
Expert
For PCs, hold down Ctrl for multiple answers. For Ipad or mobile devices, checkmark for multiple answers.
What are your financial objectives?
Income now
Tax-deferred growth
Guarantees provided
Pass assets to beneficiaries
Growth potential
Other Objectives:
What is your biggest concern or problem for coming in?
Submit Information