Questionnaire

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FAMILY DATA

Your Full Name

Date of Birth
(mm/dd/yyyy)

Birth Place

Citizenship

Spouse's Full Name

Child

Does any family member have "special needs"? Name the condition

RESIDENCE

Address	Phone No.

City	State	Zip

EMPLOYMENT DATA

Y
O
U

Occupation	Employer	How Long

Employer's Address	Phone No.

City	State	Zip

Base Salary	Estimated Bonus	Estimated Commissions	Estimated Stock Options
$	$	$	$

S
P
O
U
S
E

Occupation	Employer	How Long

Employer's Address	Phone No.

City	State	Zip

Base Salary	Estimated Bonus	Estimated Commissions	Estimated Stock Options
$	$	$	$

OTHER INCOME
	Source 1 Amount	Source 2 Amount	Source 3 Amount	Source 4 Amount
Rentals	$	$	$	$
Royalties	$	$	$	$
Fees or Commissions	$	$	$	$
Trust Income	$	$	$	$
Secondary Business Income	$	Sole Proprietor	Partnership	Corporation

SAVINGS TYPE ASSETS
List each account separately, by ownership and amount

Item	Institution	Jointly Held	Yourself	Spouse	Children
Saving Account		$	$	$	$
Saving Account		$	$	$	$
Saving Account		$	$	$	$
Credit Union		$	$	$	$
Savings Bonds(Type)		$	$	$	$
Certificate of Deposit		$	$	$	$
Certificate of Deposit		$	$	$	$
Money Market Fund		$	$	$	$
Money Market Fund		$	$	$	$
Single Premium Deferred Annuity		$	$	$	$
I.R.A.		$	$	$	$
Keogh Plan		$	$	$	$
Vested Pension		$	$	$	$
Vested Profit Sharing		$	$	$	$
Savings Plan at Work (401K, TDA)		$	$	$	$
Checking Account		$	$	$	$
Checking Account		$	$	$	$
Other		$	$	$	$
Other		$	$	$	$
Other		$	$	$	$
Other		$	$	$	$
Other		$	$	$	$
Other		$	$	$	$

INVESTMENT TYPE ASSETS
Stocks, Bonds, Mutual Funds, etc.

Item		Current Market Value
Name	# of Shares	Jointly Held	Yourself	Spouse	Children
Goverment Securities
T. Bills, Notes, Bonds		$	$	$	$
GNMA, CMO, etc.		$	$	$	$
Corporate Bonds
		$	$	$	$
		$	$	$	$
Municipal Bonds
		$	$	$	$
		$	$	$	$
		$	$	$	$
Stocks
		$	$	$	$
		$	$	$	$
		$	$	$	$
Mutual Funds
		$	$	$	$
		$	$	$	$
		$	$	$	$
Partnerships
		$	$	$	$
Other
		$	$	$	$
		$	$	$	$

REAL ESTATE

Property
	Year of Purchase	Purchase Price	Improvements or Capital Expenditures	Current Market Value (Estimated)	Terms	Type	Interest Rate	Monthly Payment	Months Remaining	Unpaid Balance
Residence		$	$	$				$	$	$
Other Home		$	$	$				$	$	$
Other Home		$	$	$				$	$	$
Land		$	$	$				$	$	$
Land		$	$	$				$	$	$
Land		$	$	$				$	$	$
Other		$	$	$				$	$	$
Other		$	$	$				$	$	$
Other		$	$	$				$	$	$

LOANS, DEBT & PERSONAL PROPERTY

Loans & Debt	(Include personal loans, college loans, home improvement loans, automobile or boat loans, passbook loans, credit card balances, store charges, checking credit lines, etc.)
Type of Loan	Monthly Payment	Months Remaining	Unpaid Balance	Insured?
	$		$	Y N
	$		$	Y N
	$		$	Y N
	$		$	Y N
	$		$	Y N
	$		$	Y N
	$		$	Y N
	$		$	Y N
	$		$	Y N

Miscellaneous Personal Property

(Show estimated market value of what you own today - NOT replacement value)

Item		Current Market Value
General Household Furnishings & Appliances		$
Artwork, Antiques, etc.		$
Jewelry, Yours		$
Jewelry, Spouse		$
Automobile #1		$
Automobile #2		$
Automobile #3		$
Boat, Trailer, etc.		$
Collections		$
Other		$

INSURANCE COVERAGES

Life Insurance
Name of Insurance Company	Family Member Insured	Owner	Total Annual Premiums	Policy Loans	Amount of Coverage
			$	$	$
			$	$	$
			$	$	$
			$	$	$
			$	$	$
			$	$	$
Smoker : Y N

Disability Insurance (personally owned policies only)
Name of Insurance Company	Family Member Insured	Waiting Period	Benefits Period	Total Annual Premiums	Amount of Coverage
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$

Long Term Care
Name of Insurance Company	Family Member Insured	Waiting Period	Benefits Period	Total Annual Premiums	Amount of Coverage
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$
				$	$

ADDITIONAL INFORMATION

Do you have a Safety Deposit Box?	Y N
Do you have an Attorney?	Y N
Do you have a Valid, Executed Wills?	Y N
Do you have an Accountant?	Y N

Please tell us what is most important to you. Check boxes below
Pay off mortgage	Education planning
Retirement planning	IRA Pension plan
Health insurance	Life insurance
Long term care insurance	Care of elderly parents/relatives

In case of a serious emergency which are the three most important you would like us to get in touch with.

EMERGENCY CONTACT PERSON 1

Name	Address

Home Phone	Work Phone	Cell Phone	E-mail	Relationship

EMERGENCY CONTACT PERSON 2

Name	Address

Home Phone	Work Phone	Cell Phone	E-mail	Relationship

EMERGENCY CONTACT PERSON 3

Name	Address

Home Phone	Work Phone	Cell Phone	E-mail	Relationship

Please use this space for additional information on any response.

Thank You.

Billy Singh

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