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1233 Shelburne Road Suite C4, South Burlington, VT 05403 don@feeonlyvt.com • www.dempseyinvestments.com

P: (802) 497-1931 • F: (802) 497-3661 • C: (802) 777-3836

FinancialPlanningQuestionnaire

PersonalInformation Date:

Client Spouse/Partner

Name:

DateofBirth:

HomeNumber:

WorkNumber:

CellNumber:

EmailAddress:

Address:

FamilyInformation

Child'sName DateofBirth

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EmploymentInformation

Client Spouse/Partner

Company

Lengthofservice

FullorPartTime Full Part Full Part

Salary GrossNet

Bonus

401k/403B%Contribution

MatchingFormula%

SelfEmploymentInformation

Client Spouse/Partner

CompanyName

FullorPartTime Full Part Full Part

RetirementPlan

NumberofEmployees

NetIncome

InsuranceandRisk

RiskProfile

InvestmentAttitude VeryConservative Conservative Moderate Aggressive

InvestmentExperience None VeryLittle Moderate Extensive

InsuranceInformation(Youmayneedtoreviewyourinsurancepoliciestogetthisinformation.)

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PermanentLifeInsurance:

Company FaceAmount Premium CashValue Owner Beneficiary

TermLifeInsurance:

Disability:

Company IncomeReplacement% ThroughWorkYes No Client Spouse

LongTermCare:

Company Coverage Premium Client Spouse

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HomeInsurance:

Company Coverage Deductible Premium

UmbrellaInsurance

Yes No

AutoInsurance:

Company Coverage Deductible Premium

EstatePlanningIssues

Doyouhaveanyofthefollowing?

Will DPOHC LivingTrust

RevocableTrust LivingWill PowerofAttorney

Howisyourjointpropertytitled?

JointTenantsbytheEntirety JointTenantsinCommon

JointTenantsWithRightsofSurvivorship Other

Pension&SocialSecurity

DefineBenefitPension(s)

Includeinformationonpensionplansthatprovideanannualincomebasedonyouryearsofserviceorincomelevel(i.e.:militarypension,statepension,etc.)

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ClientPension1 ClientPension2 SpousePension1 SpousePension2

Anticipatedannual$

StartingAge:

IncreaseratebeforeRet:

IncreaserateafterRetire:

SurvivorBenefit%:

PlannedRetirementAge Client: Spouse:

SocialSecurity Client Spouse

AgetoStart:

EarnedIncomeNow

OrAnticipated/currentbenefitAge62Age66-67Age70

Expenses

AnnualLivingExpenses(today’sdollars)

Estimateannualfiguresforexpensesrelatedtoshelter,food,clothing,transportation,insurance,loans,etc.Donotincludeincometaxes.

Now:

CurrentSurvivingHousehold:

DuringRetirement:

SingleRetireeSurvivor:

BudgetWorksheet

MonthlyExpenseItems Now Retirement

Rentorleasepayment

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Food&Householdincidentals

Gas,Electric,Heat,Water

Cellphone+HomePhone

Internet+Cable/satellite+Security

Autooperating&maintenance

Clothing&PersonalItems

Propertyimprovements&upkeep

Domestichelp,babysitting

Propertytaxes

Entertainment&vacations

Charitablecontributions

ChildCareandPets

Alimony,childsupport

Books,papers,subscriptions

Homefurnishings

Gifts,birthdays

Medicalexpenses

Otherexpenses

MortgagePayment

Autoloan

Boat&RVpayment

CreditCardPayments

Otherloanpayments

HomeEquity

LifeInsurancepremiums

MedicalInsurancepremiums

AutoInsurancepremiums

HomeInsurancepremiums

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OtherInsurance

LongTermCare

RetirementPlanSavings

OtherSavings

Assets

Listcapitalassetsincludingbankingaccounts,investmentaccounts,retirementaccounts,collegeaccounts,businessassets.

No. AssetName CurrentValue AnnualAdditions

AccountDescription(i.e.Stock,401k,bank)

1 $ $

2 $ $

3 $ $

4 $ $

5 $ $

6 $ $

7 $ $

8 $ $

9 $ $

10 $ $

11 $ $

12 $ $

13 $ $

14 $ $

15 $ $

16 $ $

17 $ $

18 $ $

19 $ $

20 $ $

Pleaseincludecopiesofyourrecentbrokerageandbankstatements.

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OtherAssetValues OtherDebts/Liabilities

House Mortgage

Car(s) CarLoans

RentalProperty1 MortgageRental1

RentalProperty2 MortgageRental2

Boats/RV Boats/RVLoans

2ndHome-Vacation Mortgage2ndHome

Collectiblescoinsetc. HomeEquityLoan

Other Other

Other Other

Other Other

Other Other

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EducationandSpecialIncome/Expenses

SpecialIncome/ExpensesListanyothersourcesofincomeorspecialexpensestobepaidfromorintoyourcapitalaccounts.

Description AnnualAmount

AnnualIncreaseRate StartingYear #Years

Children’sEducationExpenses

ChildName D.O.B./Age AgetoStartCollege CostperYear Numberof

YearsCurrentCollege

Fund

Collegefundaccounttypes(529,UGMA):

Otherfundslikescholarships,grandparentsetc.:

DoyoucontributetoaROTHIRA?Client1 Client2

Yes No Yes No

Whoarethebeneficiariesonyourretirementaccounts?

Whoareyourbeneficiariesonyourbrokerageaccounts?

Whatistherateonyourmortgage?WhatistheTerm?Howmuchtimeisleft?

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DoyouknowifyoupayPMIInsurance?

Whatistherateonyourhomeequity?Isitfixedorvariable?

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Tellmeaboutyourworstinvestmentexperience:

Whatfinancialissuekeepsyouupatnight?

Otherthoughtsthatyouwouldliketoaddressortalkabout?

Notes:

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