Client Name *

First Name

Last Name

Phone

(###)

###

####

Date *

MM

DD

YYYY

What is your current age? *

Less than 40

40 to 55

55 to 70

Older than 71

What is your goal for this portfolio? *

To grow aggressively

To grow moderately

To grow with caution

To avoid losing money

When do you expect to start drawing income from this portfolio? *

Not for at least 20 years

In 10 to 20 years

Not now, but within the next 3 to 10 years

Currently withdrawing or in the next 3 years.

With the income generated from your portfolio, over the next 5 years you plan to: *

Keep income in the portfolio to be reinvested

Withdrawal some income and reinvest the rest

Use income for special projects

Use it all for living expenses

In five years, how do you expect your standard of living to compare to what it is today? *

Substantially greater than it is today

Somewhat higher than it is today

The same as it is today

Less than it is today

How optimistic are you about the long-term (10-15 year) prospects for the US Economy? *

Very Optimistic

Somewhat Optimistic

Somewhat Pessimistic

Very Pessimistic

If the market were to suddenly experience a short-term decline of 15%, which would best describe your reaction? *

I don’t actively watch the market and wouldn’t be aware of the decline

Because I have a long-term view, I would not be concerned with a short-term decline

Although I have a long-term view, even a temporary decline of 15% would concern me

I would be very concerned because I can’t tolerate large fluctuations in my portfolio

In general, how would your best friend describe you as a risk taker? *

A real gambler

Willing to take risks after completing adequate research

Cautious

A real risk avoider