Client Questionnaire
Personal & Confidential
®
Client Information As Of:
First Name:
 (Salutation):
Last Name:
________________________________
Tax Filing Status:
________________________________
Date of Birth:
_____________________________
Address Line 1:
_____________________________
Address Line 2:
_____________________________
Previous Marriage(s)?: ________________________________
City: _____________________________
Citizenship: ________________________________
State:
__________Zip______________
Alma Mater:
________________________________
Home Phone:
_____________________________
(Country) Clubs:
________________________________
Home Fax:
_____________________________
Hobbies:
________________________________
Cell Phone:
_____________________________
Areas of Interest:
________________________________
Wedding Anniversary: _____________________________
Email:
________________________________
Business Information:
Company: _____________________________
Annual Review:
_____/01/_____
Title:
_____________________________
or Equity Review: _____/01/_____
Type of Business:
_____________________________
Financial Plan Review: _____/01/_____
Business Address: _____________________________
DRIP: _____/01/_____
City: _____________________________
Preferred Mailing Address:
Home
Business
State:
_____________Zip___________
Email Communication:
Yes
No
Work Phone:
_____________________________
Holiday Card:
Yes
No
Human Resources Contact: _____________________________
Newsletter:
Yes
No
Spouse/Partner
First Name: __________ (Salutation)_______
Last Name:
_____________________________
Date of Birth:
_____________________________
Previous Marriage(s)?: _____________________________
SPOUSE/PARTNER BUSINESS INFORMATION
Company: ________________________________
Title:
________________________________
Type of Business:
________________________________
Business Address:
________________________________
Citizenship: _____________________________
City: ________________________________
Areas of Interest:
_____________________________
State:
___________Zip________________
Hobbies:
_____________________________
Work Phone:
________________________________
Email:
________________________________
Children
Name
Date of Birth
School/Grade
Special Needs/Interests
2
Advisors (Attorney, Accountant, Personal Banker, Stockbroker, Etc.)
Advisor Type: ____________________________
Advisor Type:
_______________________________
Name (First Last):
_______________________________
Company:
_______________________________
Company: _______________________________
Address:
_______________________________
Address: _______________________________
City:
_______________________________
City: _______________________________
State:
___________Zip
State: ____________Zip________________
Name (First Last):
_______________________________
Phone:
_______________________________
Fax:
_______________________________
Email:
_______________________________
Advisor Type:
_______________________________
Name (First Last):
_______________________________
Company:
_______________________________
Company: _______________________________
Address:
_______________________________
Address: _______________________________
City:
_______________________________
City: _______________________________
State:
___________Zip
State: ____________ Zip________________
Phone:
_______________________________
Fax: _______________________________
Email:
_______________________________
Advisor Type: ____________________________
Name (First Last):
Phone:
_______________________________
Phone:
_______________________________
_______________________________
Fax:
_______________________________
Fax: _______________________________
Email:
_______________________________
Email: _______________________________
Family Goals
Please list the three most important goals that you would like to accomplish as a result of working with TriBridge Partners, LLC.
1. ________________________________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________________________________
Property
Name
Fair
Market
Value
Tax Basis
Current
Liability**
Primary
Home
Mortgage
Rate
# of
Years
Left
Ownership
H/W.J/TIC*
Address
See page 1
Second
Home
Investment
Property
Other
* H: Husband
W: Wife
** Mortgage and/or Home Equity
J: Joint
TIC: Tenants in Common
3
Personal Property (Art, Jewelry, Cars, Etc.)
Description
Ownership
H/W/J/TIC*
Current Value
Bank Accounts Cash & Cash Equivalents (Checking, Savings, Cds, T-Bills)
Account Type
(Checking, Savings,
CD, Money Market)
Account Name
See
Attached
Statement
Current Value
Ownership
H/W/J/TIC*
□
□
□
□
□
□
Investments (Non-Qualified)
Account Name
See
Attached
Statement
Current Value
Ownership
H/W/J/TIC*
□
□
□
□
□
□
* H: Husband
W: Wife
J: Joint
TIC: Tenants in Common
4
Investments: Private Equity
See
Attached
Statement
Name
Amount
Committed/
Cost Basis
Ownership
H/W/J/TIC*
Remaining
Capital
Calls
Nature of
Company
□
□
□
□
Retirement Accounts: (401[K], Ira, Profit Sharing, Deferred Compensation, 403[B] Pension, Sep)
Account Name
Account
Type**
See
Attached
Statement
Current
Value
Ownership
H/W*
Beneficiary
□
□
□
□
□
□
**Please indicate 401(k): IRA; Profit Sharing, Deferred Compensation, 403(b); Pension; or SEP
Children’s Accounts: Ugma, 529, Trust
Account Type
(UGMA, 529,
Trust)
Account Name
See
Attached
Statement
Current Value
Beneficiary
□
□
□
□
□
□
* H: Husband
W: Wife
J: Joint
TIC: Tenants in Common
5
Annuities: Fixed, Variable
Account
Name
Annuity
Type
Investment
Co.
See
Attached
Statement
Cash Value
(F/V)
Tax Basis
(F/V)
Ownership
H/W/J/TIC*
Anticipated
Annuitization
Age
Annuities: Immediate
Account
Name
Annuity
Type
Investment
Co.
Annual
Payment
Exclusion
Ratio
Ownership
H/W/J/TIC*
Start/End Age
Start:
End:
Start:
End:
Stock Option And Rsu’s Worksheets
OPTION AND RESTRICT STOCK UNIT GRANTS □ See Statement
Grant
Date
Grant Type
# Shares
Exercise
Price
(Options
Only)
First
Vesting
Date
Vesting
Frequency
# of
Vesting
Periods
Expiration
Date
Business Interests
Business Name
Fair
Market
Value
Tax
Basis
(For any business provide Insurance Documents)
* H: Husband
W: Wife
J: Joint
Business
Type
Percent
Ownership
Spouse
Active?
Children
Involved?
Future Plans
for Business
TIC: Tenants in Common
6
LIFE INSURANCE
(1)
(2)
(3)
(4)
Insured
Insurance Company
Policy Type (Term; WL;
VL; UL; etc.)
Purchase Date
Death Benefit
Annual Premium
Policy #
Cash Value
Owner
Beneficiary
Premium Due Date
Desired income in the event of your death? __________________________
Spouse’s Death? __________________________
DISABILITY INCOME INSURANCE
(1)
(2)
Insured
Insurance Company
Policy Type (Individual: BOE; Buyout, Group)
Purchase Date
Monthly Benefit
Annual Premium
Policy #
Waiting Period
Benefit Period
COLA Adjustment
( Yes / No ?)
7
Long Term Care Insurance
Insurance
Insured
Company
Purchase
Date
COLA
Daily
Annual
Waiting Benefit
Premium Due
Policy #
Adjustment
Benefit Premium
Period Period
Date
(Yes/No?)
Other Insurance Policies (Automobile, Homeowner’s, Umbrella Policy)
Type of Insurance
(Auto, Home,
Umbrella)
Carrier
Policy #
Amount
Premium
Deductible
Income Sources: (Salary, Bonus, Pension, Social Security, Sale Of Business)
Name
Income Source
Amount
Comment**
Start/End Age
Start:
End:
Start:
End:
Start:
End:
Start:
End:
Start:
End:
Start:
End:
1. AMT: Are you subject to AMT?: Yes / No
2. Do you/will you support anyone else? Parents, siblings, in-laws?
Assumptions
Client Retirement Age:__________
Spouse Retirement Age:
__________
** (e.g. Bonus amounts paid in cash vs. stock)
8
Expense
We suggest you fill in this expense list as best as you can (round numbers and approximations are fine) to give yourself a true picture of your
monthly/annual expenditures. This is done to give more accuracy to any cash flow model that we will focus on.
Monthly
Annually
Mortgage or Rent Payments (Primary Home)
Mortgage or Rent Payments (Other Real Estate)
Real Estate Property Taxes
Maintenance/Common charges
Utilities (electric, cable)
Telephone, cell phone
Private School/Education/College
Food
Clothing
Associations/Dues
Car/Travel Expenses (car pmt, gas, tolls, parking)
Insurance:
Home & Auto
Health
Life, Disability Income & LTC
Travel (plane flights, lodging, car rental, etc.)
Recreation and Entertainment (includes dining out)
Child Care/Nanny
Landscaping
Professional fees (accountant, attorney)
Housekeeper
Country Club or other memberships
Charitable Contributions
Gifts (incl. Christmas, birthdays, weddings, baby)
Savings / Investments
Savings for Education
Miscellaneous
Retirement Plan Contributions
Alimony, Child Support
Total Expenses
$ 0.00
$ 0.00
9
Expenses: Living And Other Expenses (Education, Weddings, Charity, Major Purchases, Etc.)
Current Annual Living Expenses:
Other Extraordinary
Expenses (Be Specific)*
Amount
Comment
Start/End Age
Start:
_____________________
End:
Start:
_____________________
End:
Start:
_____________________
End:
Start:
_____________________
End:
Start:
_____________________
End:
Start:
_____________________
End:
_____________________
*Education, Weddings, Charity, Major Purchases
Current Plan: Wills & Trusts
Client
□ No Will
Spouse
□ Simple Will
□ Unified Credit Planning
□ Do you have an Irrevocable Trust?
□ No Will
□ Simple Will
□ Unified Credit Planning
Current Plan: Gifting
4FMFDU0OF
Do you or your spouse plan to gift in the future?
Yes No
Comments
Yes No
Would you consider using gifting as a planning tool?
If so, expected number of gift recipients:
Have you or your spouse ever filed a gift tax return?
YesNo
Current Plan: Charitable Requests
Name:
Name:
Amount Gifted Per Year:
Amount Gifted Per Year:
Current Plan: Savings Plan
Do you contribute to a 401(k) plan?
Yes 1R
Amount/ year:
Company Match
Yes
No
Does your spouse contribute to a 401(k) plan?
YesNo Amount/ year:
Company Match
Yes
No
10
Risk Assessment Questionnaire
The Risk Assessment Questionnaire helps to determine the best asset mix for an investment, based on the answers given to the questions below.
Time Horizon: Your current situation and future income needs.
1. When do you expect to start drawing income?
Not for at least 20 years
In 10 to 20 years
In 5 to 10 years
Not now, but within 5 years
Immediately
Long-Term Goals and Expectations: Your views of how an investment should perform over the long term.
2. What is your goal for your investments?
To grow aggressively
To grow significantly
To grow moderately
To grow with caution
To avoid losing money
3. Assuming normal market conditions, what would you expect from your investments over time?
To generally keep pace with the stock market
To slightly trail the stock market, but make a good profit
To trail the stock market, but make a moderate profit
To have some stability, but make modest profits
To have a high degree of stability, but make small profits
4. Suppose the stock market performs unusually poorly over the next decade, what would you expect from this investment?
To lose money
To make very little or nothing
To eke out a little gain
To make a modest gain
To be little affected by what happens in the stock market
Short-Term Risk Attitudes: Your attitude toward short-term volatility.
5. Which of these statements would best describe your attitudes about the next three years' performance of this investment?
I don't mind if I lose money
I can tolerate a loss
I can tolerate a small loss
I'd have a hard time tolerating any losses
I need to see at least a little return
Short-Term Risk Attitudes:
6. Which of these statements would best describe your attitudes about the next three months' performance of this investment?
Who cares? One calendar quarter means nothing
I wouldn't worry about losses in that time frame
If I suffered a loss of greater than 10%, I'd get concerned
I can only tolerate small short-term losses
I'd have a hard time stomaching any losses
11
Goals:
1. Ideal “retirement age”
2. Ideal family size if known (current plan)
3. Major purchases (e.g. home upgrade, second home, major projects, education expenses)
4. Education for children (public/private K-12 and/or college)
5. How would your life change if your spouse passed away (financially/ work hours/ living situation)
6. What amount are you currently saving on an annual basis and what would be a realistic target?
7. Any other relevant financial goals:
12
Notes:
www.tribridgepartners.com | 240.422.8799 (local) | 855.333.6399 (toll-free)
One East Pratt Street | Suite 902 | Baltimore, MD 21202
6550 Rock Spring Drive | Suite 190 | Bethesda, MD 20817
5280 Corporate Drive | Suite C250 | Frederick, MD 21703
38 South Potomac Street | Suite 303 | Hagerstown, MD 21740
BCC2706 815