Questionnaire - Polaris Financial Group

Please complete this confidential questionnaire.

Personal Data and Financial Summary

Personal Information

Client

First Name

Last Name

Phone

Age

Sex

Spouse

Name

Age

Sex

Child 1

Name

Age

Child 2

Name

Age

Child 3

Name

Age

PERSONAL QUESTIONS:

Do you have a will?
YesNo

Name of Executor:

Do you have a revocable living trust?
YesNo

Name of Trustee:

Do you have an irrevocable trust?
YesNo

Name of Trustee:

Do you expect to care for a child or parent?
YesNo

Explain:

What is the name of your Financial Advisor?

What do you like or dislike about them?

What is the name of your attorney?

What is the name of your accountant?

What do you like or dislike about your accountant?

Do you expect an inheritance (if so, how much)?

Do you currently have a long term care plan in place (please explain)?

What percentage of your investments would you be comfortable losing?
<10%10-20%>20%

What keeps you up at night?

Home Address

Street

City

Home Phone

Retirement Data:

Client

Client is retired

Client expects to retire at age

Spouse

Spouse is retired

Spouse expects to retire at age

Tax Rates:

Pre-retirement years:

Income tax rate:

Optional rate change:

Starting at age:

Retirement years:

Income tax rate:

Optional rate change:

Starting at age:

Heirs’ Income tax rate:

Optional rate change:

Starting at age:

Capital gains tax rate:

Optional rate change:

Starting at age:

Charitable Organizations

If the Client(s) have only one specific charity that they plan to donate to, enter the name of the Charity:

Wealth Planning Goals

What are the three most important Wealth Planning Goals you want to accomplish over the next several years?

Desired Spendable Cash Flow

Answer in terms of an annual after-tax amount in today’s dollars. You may select a maximum of seven categories. If you enter your own category name, you are limited to 33 characters:

Description:Living ExpensesMajor PurchasesTravelOther

Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Inflation rate

Optional rate change

Starting at age

Description 2:Living ExpensesMajor PurchasesTravelOther
Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Inflation rate

Optional rate change

Starting at age

Description 3:Living ExpensesMajor PurchasesTravelOther
Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Inflation rate

Optional rate change

Starting at age

Description 4:Living ExpensesMajor PurchasesTravelOther
Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Inflation rate

Optional rate change

Starting at age

Expected Cash Flow

You may select a maximum of seven categories. If you include Social Security as one of your selections, you can enter the amount if it is known, or you can use the System's Social Security Calculator to estimate the benefits.

Social Security Calculator information (optional):

Client

Annual income:

Years employed:(must be at least 10 years)

Expects to collect Social Security Benefits at age:

Annual income in retirement:

Spouse

Annual income:

Years employed:(must be at least 10 years)

Expects to collect Social Security Benefits at age:

Annual income in retirement:

Do not include interest or principal withdrawals from Liquid Investments here. Also, do not include Defined Benefit Pension income here. If you enter your own category name, you are limited to 33 characters:
Description 1:
Social Security BenefitsWork After RetirementRental PropertyRoyaltiesCurrent Life InsuranceOther
Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Growth Assumption

Optional rate change

Starting at age

Description 2:
Social Security BenefitsWork After RetirementRental PropertyRoyaltiesCurrent Life InsuranceOther

Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Growth Assumption

Optional rate change

Starting at age

Description 3:
Social Security BenefitsWork After RetirementRental PropertyRoyaltiesCurrent Life InsuranceOther

Other

After tax amount

From Age

To Age

After tax amount

From Age

To Age

After tax amount

From Age

To Age

Optional Growth Assumption

Optional rate change

Starting at age

Retirement Plan Assets

Client

Defined Benefit Pension

Expected annual pre-tax income:

Starting at age:

Defined Contribution Plan:

Profit Sharing/401(k) $

Client’s Estimated Values

Client’s Estimated Cost Basis

IRA $

Client’s Estimated Values

Client’s Estimated Cost Basis

Keogh $

Client’s Estimated Values

Client’s Estimated Cost Basis

SEP $

Client’s Estimated Values

Client’s Estimated Cost Basis

Growth rate

Optional rate change

Management Fee:

Client will be making annual deposits of

Starting at age

For years

The Retirement Plan assets qualify for use of a "stretch-out".
(The heirs' income tax on inherited Retirement Plan assets is not paid on the death of the pensioner, i.e., the income tax continues to be deferred. Be certain to confirm the availability of this technique with client's legal and tax advisers.)

Roth Defined Contribution Plan:

Roth Estimated Value: $

Estimated Cost Basis: $

Growth Rate %

Optional rate change: %

Starting at age

Management Fee %

Client will be making annual deposits of $

For years

Inherited Defined Contribution Plan:

Value at inheritance: $

Cost Basis at Inheritance: $

Estimated Current Value: $

Estimated Current Cost Basis: $

Growth rate

Optional rate change: %

Starting at age

Management Fee %

Inherited Roth Defined Contribution Plan:

Estimated Current Value: $

Estimated Current Cost Basis: $

Growth rate

Optional rate change: %

Starting at age

Management Fee %

Retirement Plan Assets (continued)

Defined Benefit Pension:

Expected annual pre-tax income: $

Starting at age:

Defined Contribution Retirement Plan:

Spouse’s Estimated Values

Profit Sharing/401(k) $

IRA $

Keogh

SEP

Spouse’s Estimated Cost Basis

Profit Sharing/401(k) $

IRA $

Keogh

SEP

Growth rate

Optional rate change: %

Management Fee %

Spouse will be making annual deposits of

Starting at age

For years

Roth Defined Contribution Plan:

Roth Estimated Value: $

Estimated Cost Basis: $

Growth Rate %

Optional rate change: %

Starting at age

Management Fee %

Client will be making annual deposits of $

For years

Inherited Defined Contribution Plan:

Value at inheritance: $

Cost Basis at Inheritance: $

Estimated Current Value: $

Estimated Current Cost Basis: $

Growth rate

Optional rate change: %

Management Fee %

Inherited Roth Defined Contribution Plan:

Estimated Current Value: $

Estimated Current Cost Basis: $

Growth rate

Optional rate change: %

Management Fee %

Liquid Asset Accounts

Taxable Accounts: Cash/Checking, Savings, Certificates of Deposit

Accounts	Description (optional)	Estimated Value	Sales Charge	Management Fee
1.
2.
3.
4.
5.

Accounts	(Assumed Interest Rate) Rate:	(Assumed Interest Rate) Optional Change Rate:	(Assumed Interest Rate) Starting at age:	(Future Deposits) Amount of Future Annual Deposits(Optional)	(Future Deposits) For How Many Years?(Optional)
1.
2.

Tax Exempt Accounts: Municipal Bonds/Tax Exempt Bond Funds, Tax Exempt Bond Funds, etc.

Accounts	Description (optional)	Estimated Value	Sales Charge	Management Fee
1.
2.
3.
4.
5.

Accounts	(Assumed Interest Rate) Rate:	(Assumed Interest Rate) Optional Change Rate:	(Assumed Interest Rate) Starting at age:	(Future Deposits) Amount of Future Annual Deposits(Optional)	(Future Deposits) For How Many Years?(Optional)
1.
2.

Liquid Asset Accounts(continued)

Equity Accounts: Stocks, Mutual Funds, etc

Accounts	Description (optional)	Cost Basis	Estimated Value	Sales Charge	Management Fee	Amount of Future Annual Deposits (if any)	Deposits for How Many Years?
1.
2.
3.
4.
5.

Accounts	(Assumed Capital Growth Rate) Rate:	(Assumed Capital Growth Rate) Optional Change Rate:	(Assumed Capital Growth Rate) Starting at age:	(Assumed Annual Dividend Rate) Rate:	(Assumed Annual Dividend Rate) Optional Change Rate:	(Assumed Annual Dividend Rate) Starting at age:	(Dividend Tax Rate) Rate:	(Dividend Tax Rate) Optional Change Rate:	(Dividend Tax Rate) Starting at age:	(Portfolio Turnover Rate) Rate:	(Portfolio Turnover Rate) Optional Change Rate:	(Portfolio Turnover Rate) Starting at age:	Turnover Sales Charge
1.
2.

Tax Deferred Accounts: Stocks, Mutual Funds, etc.

Accounts	Description (optional)	Estimated Value	Cost Basis	Sales Charge	Management Fee	Death Benefit Guarantee Fee	Annual Administrative Fee
1.
2.
3.
4.
5.

Accounts	(Assumed Interest Rate) Rate:	(Assumed Interest Rate) Optional Change Rate:	(Assumed Interest Rate) Starting at Age:	(Future Deposits) Amount of Future Annual Deposits(Optional)	(Future Deposits) For How Many Years?(Optional)	Use a “Stretch-out” Strategy
1.						YesNo
2.						YesNo

*This Tax Deferred Account qualifies for use of a "stretch-out" strategy.
(The heirs' income tax on inherited tax deferred accounts is not paid on the death of the account owner, i.e., the income tax continues to be deferred.) If Yes, be certain to confirm the availability of this technique with client's legal and tax advisers.

Charitable Bequests

Account	Include Charitable Bequests	Effective at Age	Up to What Amount OR Percent of Asset Value
Taxable Account #1	YesNo
Taxable Account #2	YesNo
Tax Exempt Account #1	YesNo
Tax Exempt Account #2	YesNo
Equity Account #1	YesNo
Equity Account #2	YesNo
Tax Deferred Account #1	YesNo
Tax Deferred Account #2	YesNo

Reinvestment of Funds

Excess funds should be reinvested as follows:
(The total of all percentages must equal 100%.)

% of Funds	Account
	Taxable Assets #1
	Taxable Assets #2
	Tax Exempt Assets #1
	Tax Exempt Assets #2
	Equity Assets #1
	Equity Assets #2
	Tax Deferred Assets #1
	Tax Deferred Assets #2
100%	TOTAL

Illiquid Assets – Principal Residence

For each asset type that the client owns, enter its current estimated fair market value. Include any loans against assets. You may select a maximum of ten categories:

Principal Residence:

Estimated value: $

Growth assumption: %

Loan information (if any)

Type of Loan

Interest onlyAmortized

Loan balance: $

Years remaining:

Annual interest rate: %

Refinance of loan (if planned)

in year:

Type of Loan
Interest onlyAmortized

Loan amount: $

Years of loan:

Annual interest rate: %

Sale (if planned)

in year:

Cost basis at time of sale: $

Assumed sales price: $

Excludable gain: $

Replacement residence

Estimated cost: $

Growth assumption: %

Loan information (if any)

Type of Loan

Interest onlyAmortized

Loan amount: $

Years of Loan:

Annual interest rate: %

Refinance of loan (if planned)

in year:

Type of Loan
Interest onlyAmortized

Loan amount: $

Years of loan:

Annual interest rate: %

Sale (if planned)

in year:

Cost basis at time of sale: $

Assumed sales price: $

Excludable gain: $

Include Charitable Bequests

Effective at age:

Up to $ in value,

or % of asset value

Illiquid Assets (continued)

Descriptions
Personal PropertyInvestment Real EstateClosely Held StockOther

If other

Current Value $

Growth Assumption %

Loan information (if any)

Type of Loan

Interest onlyAmortized

Loan Balance: $

Years remaining:

Annual interest rate: %

Refinance of loan (if planned)

in year:

Type of Loan
Interest onlyAmortized

New Loan amount: $

Years of loan:

Annual interest rate: %

Liquidation (if planned)

Cost basis:$

Assumed sales price: $

In single year:

Partial amount $

from year

to year

Include Charitable Bequests

Effective at age:

Up to $ in value,

or % of asset value

Descriptions
Personal PropertyInvestment Real EstateClosely Held StockOther

If other

Current Value $

Growth Assumption %

Loan information (if any)

Type of Loan

Interest onlyAmortized

Loan Balance: $

Years remaining:

Annual interest rate: %

Refinance of loan (if planned)

in year:

Type of Loan
Interest onlyAmortized

New Loan amount: $

Years of loan:

Annual interest rate: %

Liquidation (if planned)

Cost basis:$

Assumed sales price: $

In single year:

Partial amount $

from year

to year

Include Charitable Bequests

Effective at age:

Up to $ in value,

or % of asset value

Life Insurance

List below any life insurance policies in which the client and/or spouse are the insured, owner or beneficiary.

Insurance Company

Policy Type

Date Issued:

Face Amount

Insured

Owner

Beneficiary

Insurance Company

Policy Type

Date Issued:

Face Amount

Insured

Owner

Beneficiary

Insurance Company

Policy Type

Date Issued:

Face Amount

Insured

Owner

Beneficiary

Insurance Company

Policy Type

Date Issued:

Face Amount

Insured

Owner

Beneficiary

Insurance Company

Policy Type

Date Issued:

Face Amount

Insured

Owner

Beneficiary

Gifting

Prior Gifts:

Total prior gifts in excess of available annual exclusions:

Total prior gifts allocated to the use of lifetime gift exemption:

Prior Gift Taxes Paid:

Total prior gift taxes paid by client and/or spouse:

Portion of total paid in the last 12 months (if any):

Portion of total paid in the 12 months prior to that (if any):

Client has _____ Gift Exclusions available

Spouse has ____ Gift Exclusions available

Desired Gifting	Gifts in The Form of (cash, interest from assets, stock)	If Investment, Indicate Details
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Cash FlowInvestmentsTuition PaymentsMedical Expenses	Yield Sales Charge: Management Fee: Other fees:
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Cash FlowInvestmentsTuition PaymentsMedical Expenses	Yield Sales Charge: Management Fee: Other fees:
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Cash FlowInvestmentsTuition PaymentsMedical Expenses	Yield Sales Charge: Management Fee: Other fees:
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Cash FlowInvestmentsTuition PaymentsMedical Expenses	Yield Sales Charge: Management Fee: Other fees:
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Cash FlowInvestmentsTuition PaymentsMedical Expenses	Yield Sales Charge: Management Fee: Other fees:

Desired Gifting to Life Insurance	Life Insurance Amounts	Insured:	If Charity Benefits: Premium Paid by	If Loan from Third Party: Loan Interest
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Premium Death Benefits:	ClientSpouseHeirsDo not indicate	GiftsLoan from third party	Rate: Pay via gift for yrs:Accrue for yrs:
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Premium Death Benefits:	ClientSpouseHeirsDo not indicate	GiftsLoan from third party	Rate: Pay via gift for yrs:Accrue for yrs:
Currently Gifting Start in ___ yearsTo Benefit:HeirsCharity	Premium Death Benefits:	ClientSpouseHeirsDo not indicate	GiftsLoan from third party	Rate: Pay via gift for yrs:Accrue for yrs:

Estate Planning Information

Client(s) have a will

Distribution instructions:

All to surviving spouseOthers

If Others:

Client(s) have trust

Purpose:

Trust Type:

Purpose:

Income Beneficiaries:

Remainder Beneficiaries:

Trust Type:

Purpose:

Income Beneficiaries:

Remainder Beneficiaries:

Trust Type:

Purpose:

Income Beneficiaries:

Remainder Beneficiaries:

The distribution patterns under the trust are:

The provisions of any trust in which Client(s) may have a beneficial interest:

Client(s) expect to receive an inheritance in the future in the amount of $

Estimated date:

From Whom:

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