Intake Form
Δ
1. PERSONAL INFORMATION
Name
(Required)
First
Last
Date of Birth
MM slash DD slash YYYY
SS#
DL#
Phone
(Required)
Cell Phone
Email
(Required)
College
Comany
Job Title
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country
Do You
Own
Rent
2. SPOUSE DETAILS
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Phone
Cell Phone
Email
College
Comany
3. CHILDREN
Name
First
Age
Gender
Male
Female
Marital Status
Yes
No
Name
First
Age
Gender
Male
Female
Marital Status
Yes
No
Name
First
Age
Gender
Male
Female
Marital Status
Yes
No
Name
First
Age
Gender
Male
Female
Marital Status
Yes
No
4. FINANCIAL SNAPSHOT
Current Annual Income
Spouse / Partner
Other Income
Approximate Monthly Discretionary Income
Do you keep and follow a budget?
Yes
No
Do you have any comments you want to add.
5. INSURANCE
Life Insurance
Insured Name
Amount
Type
Term
Perm
Insured Name
Amount
Type
Term
Perm
When was your life insurance needs last reviewed by a professional
Health Insurance
Carrier Name
Type of Coverage
Cost
Disability
Carrier Name
Type of Coverage
Type
Long
Short
Cost
Long-Term Care
Carrier Name
Type of Coverage
Cost
Home Insurance
Carrier Name
Type of Coverage
Cost
Auto(s) Insurance
Carrier Name
Type of Coverage
Cost
Umbrella Policy
Carrier Name
Type of Coverage
Cost
6. ESTATE / PROSPERITY PLANNING
Do you have a will
Yes
No
Do you have a trust
Yes
No
Type
Setup Date
MM slash DD slash YYYY
When was your will/trust last reviewed by a professional?
When was the last date you reviewed beneficiary
Designations on the following accounts? (Life Insurance, IRA, 401K, Annuity, etc.)
Do you have an Estate Planning Attorney
Yes
No
Name
Phone
Do you have a Financial Advisor
Yes
No
Name
Phone
Do you have a CPA
Yes
No
Name
Phone
Do you have any comments you want to add.
7. FOR BUSINESS OWNERS ONLY
Name of business
Business Structure? (LLC, S-Corp, etc.)
Date business formed
Number of employees
Business Insurance? Carrier Name
Limit of Liability
Cost
Interested/Current - Please check any items of interest and/or if currently in place.
Business Continuation Planning
Buy/Sell Agreement
Key Employee Insurance
Disability Income
Long-Term Care Insurance
Qualified Plans 401(k), SEP, etc.)
Group Health Insurance
Non-qualified Retirement Plans
Business Overhead Expense Protection
Other
Do you have any comments you want to add.
8. FUTURE PLANNING
Please check any items below that are involved with your near future plans.
Moving
Career Change
Business Startup
Large purchases/expenses
Children
Inheritance
Other
Please explain your plan
Are there any other concerns you would like to address
Yes
No
If yes, explain
Notes and next steps
Do you have any comments you want to add.
Net Worth Calculation Worksheet
An important step in reviewing your financial status and determining appropriate investments is to calculate your net worth (assets - debts). Periodically your net worth should be tabulated to review your progress and compare it with your financial goals.
9. ASSETS (What You Own)
Cash
Checking Account
Savings Accounts
Other
Personal Property: (Present Value)
Automobiles
Collections/Firearms
Recreational Vehicle/Boat
Jewelry and Furs
Other
Real Estate/Property
Primary Home
Rental/Secondary
Rental/Secondary
Land
Other
Investments: (Market Value)
Certificates of Deposit
Stocks
Bonds
Mutual Funds
Cash Value of Life Insurance
Annuities
Annuities
His
His
Annuities
Hers
Hers
IRAs (Type: SEP, ROTH, Traditional)
IRAs (Type: SEP, ROTH, Traditional)
Hers
Hers
IRAs (Type: SEP, ROTH, Traditional)
Hers
Hers
IRAs (Type: SEP, ROTH, Traditional)
Hers
Hers
IRAs (Type: SEP, ROTH, Traditional)
His
His
IRAs (Type: SEP, ROTH, Traditional)
His
His
IRAs (Type: SEP, ROTH, Traditional)
His
His
Company Plans (Type: 401(k), 403(b), 457)
Company Plans (Type: 401(k), 403(b), 457)
His
His
Company Plans (Type: 401(k), 403(b), 457)
Hers
Hers
Business Estimated Value
Business Estimated Value
Other
Do you have any comments you want to add.
10. LIABILITIES (What You Owe)
Current Debts
Medical
Credit Cards
Department Store Cards
Back Taxes
Legal
Alimony
Other
Mortgages
Primary Home
Rental/Secondary
Rental/Secondary
Land
Other
Loans
Bank/Finance Company
Bank/Finance Company
Automobile
Recreational Vehicle/Boat
Education
Life Insurance
Personal (from family / friends)
Other
Total Assets
Total Liabilities
Total Assets Minus Total Liabilities = Net Worth
Client Name
Signature
Date
MM slash DD slash YYYY
Do you have any comments you want to add.
11. Risk Tolerance Questionnaire
What is your age?
56+
46 to 55
46 to 55
36 to 45
18 to 35
In approximately how many years will you begin withdrawing funds from your investments to satisfy your retirement goals?
Immediately
1-5 Years
6-10 Years
11-20 Years
Over 20 years
Once you begin to withdraw funds for your primary purpose or investment objective, over how long a period do you anticipate the withdrawals to continue?
I expect to withdraw all funds in a single lump-sum
1-5 Years
6-10 Years
11-20 Years
Over 20 years
Which one of the following statements best describes your attitude towards the trade-off between risk and return?
I am primarily concerned with limiting risk. I am willing to accept lower expected returns in order to limit my chance of loss.
Limiting risk and maximizing return are of equal importance to me. I am willing to accept moderate risk and moderate chance of loss in order to achieve moderate returns.
I am primarily concerned with maximizing the returns of my investments. I am willing to accept high risk and high chance of loss in order to maximize my investment return potential.
Inflation can greatly diminish the effective returns of your portfolio. Please specify which of the following best summarizes your attitudes regarding investing and inflation.
I prefer a portfolio that has the potential to return substantially more than inflation over the long run and I am willing to accept large short-term fluctuations in value (and a greater potential for loss) to achieve this goal.
I prefer a portfolio that has the potential to moderately exceed inflation over the long run and I am willing to accept moderate short-term fluctuations in value (and a moderate potential for loss) to achieve this goal.
I prefer to minimize short-term fluctuations in portfolio value (and the potential for loss) as much as possible, even if it means that my portfolio has the potential to only keep pace with or slightly exceed inflation.
Sometimes investment losses are permanent, sometimes they are prolonged, and sometimes they are short-lived. How might you respond when you experience investment losses?
I would sell my investments immediately if they suffered substantial declines.
Although declines in investment value make me uncomfortable, I would wait at least one year before adjusting my portfolio.
I can endure significant declines in the value of my investments and would wait at least one year before adjusting my portfolio.
Even if my investments suffered a significant decline over several years, I would continue to follow my long-term investment strategy and not adjust my portfolio.
Do you need current income (that is, will you take regular withdrawals from your savings and investment accounts)?
Yes
No
The following graphs show the historical year-by-year returns for three hypothetical portfolios over a 20-year period. The average annual return over the 20-year period is also indicated. Which portfolio would you choose?
Portfolio A Average Annual Return = 3%
Portfolio B Average Annual Return = 6%
Portfolio C Average Annual Return = 10%
Would you like to consider alternative/ non-stock market-based investments?
Yes
No
Do you have adequate funds for emergency expenses?
Yes
No
Client Name
Signature
Date
MM slash DD slash YYYY
Do you have any comments you want to add.
Important Financial Planning Notice and Information
Why work with a CFP® (Certified Financial Planner)? Anyone can call themselves a “financial planner”. Very few have taken the time and effort to gain the experience and knowledge needed to truly be able to give advice on a multiple of financial topics. Advisors who hold the CFP® designation, through intense coursework and testing have shown competency, ethics and professionalism in all areas of financial planning. Currently, approximately 1% of advisors hold this designation. Why work with an Independent Investment Advisor? You probably noticed on our business card/website we are not affiliated with any large insurance companies or brokerage firms. This is because Bennett & Porter Wealth Management is an independent firm able to offer you a wide range of non-proprietary investments. Therefore, investment selection is based solely on your needs and goals, not bound by large company sales quotas and agendas. Advisors working under this arrangement can only access/offer investments approved by that firm, which can severely limit your investment options.
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