Today’s Date: Office: CLIENT INFORMATION

Name: Date of Birth: Nickname: Age:

Retired: Yes: No: Actual/Planned Year of Retirement:

Spouse/Partner Name: Date of Birth: Nickname: Age:

Retired: Yes: No: Actual/Planned Year of Retirement:

Anniversary Date:

CONTACT INFORMATION

Street Address: City: State: ZIP Code:

You Spouse

Phone (Cell): Phone (Home/Work): Email:

Number of Children: Number of Grandchildren:

Do you or your spouse have any health issues?

Does anyone help you make financial decisions?

Do any of your children or grandchildren have any special needs?

CHILDREN AGE STATE OF RESIDENCE

Yes NoIf Yes, list below

Please check one email address and one phone number above to indicate a primary contact for the household to receive legal disclosures

Phone (Cell): Phone (Home/Work): Email:

Questionnaire

Page 1 of 5

CarlsonFinancial.comInvestment Advisory Services offered through Carlson Financial

How did you hear about us?

GENERAL INFORMATION FINANCIAL PLANNING OBJECTIVES Do you have an Accountant? Yes No Is your current cash flow sufficient

and comfortable? Yes No

Do you have a financial Advisor? If yes, name:

Yes No Do you live off interest your investment dollars earn?

Yes No

Do you have an Attorney?If yes, name:

Yes No Do you anticipate any significant changes in cash flow?

Yes No

Do you have a Will? Do you have a Living Will?

Yes Yes

No No

Are you planning any major lifestyle changes?

Yes No

Would you like to leave money to children?

Yes No Do you foresee any purchase greater than $15,000 in the next 3 years?

Yes No

Do you expect to care for a child or parent?

Yes No Do you contribute to a charity? Yes No

Do you have an umbrella policy? Yes No Do you have a living Trust? Yes No Do you have a POA for Assets? Do you have a POA for Health?

Yes Yes

No No

Do you expect to receive an inheritance?

Yes No

How did you acquire your wealth?

What is your risk tolerance?

Conservative Moderately conservative Moderate Moderately aggressive Aggressive

How involved do you like to be with your investments?

If something were to happen to you tomorrow, who do you want taken care of?

How would you describe your investment knowledge? (None, limited, average, good, high, expert)

Are you more concerned about growing your assets or protecting what you already have?

What are your primary concerns for today’s visit?

Fact Find

Page 2 of 5

CarlsonFinancial.comInvestment Advisory Services offered through Carlson Financial

Employment History You Spouse

Most Recent/Current Company Most Recent/Current Company

Name: Name:

Occupation: Occupation:

Years: Years:

Previous Employer Previous Employer

Name: Name:

Occupation: Occupation:

Years: Years:

Real Estate

Estimated Value of Home: $ Second Home Value: $

Remaining Mortgage Amt: $ Remaining Mortgage Amt: $

Location:

Rental Property Value: $ Other: $

Remaining Mortgage: $ Remaining Mortgage: $

Sources of Income You Spouse

Current Employment: $ Current Employment: $

Pension: $ Pension: $

Social Security: $ Social Security: $

Rental Income: $ Rental Income: $

Other: $ Other: $

How much are your monthly expenses?

Does pension continue upon death? Yes No Amount: $

Is there a pension that hasn’t started? Yes No Amount: $

Fact Find

Page 3 of 5

CarlsonFinancial.comInvestment Advisory Services offered through Carlson Financial

IRA & RETIREMENT ACCOUNT INFORMATION Where is Account held

(Bank, Broker, Employer) Type Owner Approximate Value

$

$

$

$

$

$

MUTUAL FUNDS – BROKERAGE ACCOUNTS Type Name of Institution Balance

$

$

$

$

$

ANNUITIES Name of Company

Type of Annuity

Original Investment Current Value Ownership Date Acquired

$

$

$

$

BANK ACCOUNTS, CREDIT UNIONS & CD’S Name of Institution Balance Due Date

$

$

$

$

Fact Find

Page 4 of 5

CarlsonFinancial.comInvestment Advisory Services offered through Carlson Financial

LIFE INSURANCE/LONG-TERM CARE POLICIES Company Type Face

Amount Cash Value Annual Premium Insured Beneficiary

OTHER ASSETS/POLICIES (STOCKS/BONDS) Description Value

$

$

$

$

$

$

DEBTS (Other than mortgage) Type of Debt Amount

$

$

$

$

$

Notes

Fact Find

Page 5 of 5

CarlsonFinancial.comInvestment Advisory Services offered through Carlson Financial