ConfidentialClient Questionnaire

Our Privacy Commitment to You

Your trust is important to us. It is one of our most valuable assets. One way we earn your trust is by protecting your personal information. We will not sell your information or share it with third parties for marketing purposes.

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SECTION A: PERSONAL DATA

SECTION B: DEPENDENTS/CHILDREN

Name (First, Middle, Last) Name (First, Middle, Last)

Zip ZipCity City

# of years at this address # of years at this address

State State

Address Address

Client 1

Client 1

Client 2

Client 2

Assets Liabilities

Mobile Phone Mobile Phone Home Phone Home Phone

E-mail Address OK to be contacted by E-mail? E-mail Address OK to be contacted by E-mail?

Employer Name Employer NameOccupation Occupation

Name of Dependent/Child Relationship Age Name of Dependent/Child Relationship Age

□ Yes □ Yes

Marital Status Marital StatusAge Age

SECTION C: COMMON LIFE EVENTS

SECTION D: HOUSEHOLD INCOME

SECTION F: ASSETS AND LIABILITIES

SECTION E: TYPES OF ASSETS OWNED

Please check all the events that have occurred in the past year or you anticipate occurring in the next year.

Please indicate your approximate annual household income.

Please indicate your total assets and liabilities.

Please indicate all of the assets you own.

□ New child or grandchild

□ New job or promotion

□ Buy or sell a business

□ Inheritance

□ Change in marital status

□ New investment or insurance

□ Buy or sell a home

□ Death of a family member

□ Retirement

□ Under $50,000

□ $50,001- $75,000

□ $75,001- $100,000

□ $100,001- $150,000

□ $150,001- $250,000

□ $250,001- $500,000

□ $500,001- $1 million

□ $1 million +

□ Under $100,000

□ $100,001- $250,000

□ $250,001- $500,000

□ $500,001- $1 million

□ $1 million +

□ $2 million +

□ $5 million +

□ Under $100,000

□ $100,001- $250,000

□ $250,001- $500,000

□ $500,001- $1 million

□ $1 million +

□ $2 million +

□ $5 million +

□ Primary Residence

□ Other Real Estate

□ Savings Accounts/CDs

□ Mutual Funds

□ Stocks/Bonds

□ Life Insurance

□ Business/Practice

□ IRA/SEP

□ Annuities

□ 401(k)

□ Other Retirement Accounts

□ Other:

What is the best investment you have ever made?

What is the worst investment you have ever made?

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SECTION H: RISK MANAGEMENT

SECTION I: WEALTH ACCUMULATION

Please rate each category on its level of importance to your goals, as well as your level of satisfaction with your current results in each category.

Please rate each category on its level of importance to your goals, as well as your level of satisfaction with your current results in each category.

Not Important Very

ImportantNot

Satisfied Very Satisfied

Maintaining your family’s lifestyle in event of death or disability

□ □ □ □ □ □ □ □ □ □Payment of medical expenses □ □ □ □ □ □ □ □ □ □Personal and business liability coverage □ □ □ □ □ □ □ □ □ □Level of volatility of your investments □ □ □ □ □ □ □ □ □ □Unforeseen costs of caring for an aging or disabled relative

□ □ □ □ □ □ □ □ □ □Other: □ □ □ □ □ □ □ □ □ □

Not Important Very

ImportantNot

Satisfied Very Satisfied

Education for children or grandchildren □ □ □ □ □ □ □ □ □ □New or second home □ □ □ □ □ □ □ □ □ □Special vacation/event □ □ □ □ □ □ □ □ □ □Purchase of business □ □ □ □ □ □ □ □ □ □Other: □ □ □ □ □ □ □ □ □ □

SECTION G: FINANCIAL POSITION

Please rate each category on its level of importance to your goals, as well as your level of satisfaction with your current results in each category.

Not Important Very

ImportantNot

Satisfied Very Satisfied

Budgeting (living within your means) □ □ □ □ □ □ □ □ □ □Amount of emergency cash reserves □ □ □ □ □ □ □ □ □ □Safety of cash reserves □ □ □ □ □ □ □ □ □ □Rate of return on cash reserves □ □ □ □ □ □ □ □ □ □Liquidity cash reserves □ □ □ □ □ □ □ □ □ □Eliminating debt □ □ □ □ □ □ □ □ □ □Other: □ □ □ □ □ □ □ □ □ □

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SECTION J: RETIREMENT PLANNINGPlease rate each category on its level of importance to your goals, as well as your level of satisfaction with your current results in each category.

Not Important

Very Important

Not Satisfied

Very Satisfied

Level of retirement income □ □ □ □ □ □ □ □ □ □Duration of retirement □ □ □ □ □ □ □ □ □ □Continuation of retirement income at death □ □ □ □ □ □ □ □ □ □Taxation of retirement income (including Social Security)

□ □ □ □ □ □ □ □ □ □Maintaining purchasing power during retirement □ □ □ □ □ □ □ □ □ □Preparation for nursing home/care costs □ □ □ □ □ □ □ □ □ □Other: □ □ □ □ □ □ □ □ □ □

SECTION L: ADDITIONAL INFORMATIONIn order to provide the most comprehensive analysis possible, we ask that you gather all the financial information you can for our appointment. The information that you provide will determine how comprehensive the analysis will be. Please consider bringing the following documents:

• Investment account statements, including retirement and 401k statements

• Insurance policy information

• Employee benefits information

• Documents relating to debts you may owe, such as loans or mortgages

• Income and cash flow information, such as recent pay stubs and Income tax returns

Securities offered through Signator Investors, Inc. Member FINRA, SIPC. Boston, MA 02116

SECTION K: OTHERPlease rate each category on its level of importance to your goals, as well as your level of satisfaction with your current results in each category.

Not Important

Very Important

Not Satisfied

Very Satisfied

Charitable giving □ □ □ □ □ □ □ □ □ □Consolidated inventory of assets, accounts and property

□ □ □ □ □ □ □ □ □ □Understanding your employee benefits package □ □ □ □ □ □ □ □ □ □Understanding if your existing financial arrangements will achieve your goals

□ □ □ □ □ □ □ □ □ □

Coordination of and communication between advisors (attorney, CPA, etc.)

□ □ □ □ □ □ □ □ □ □

Having a step by step plan to accomplish your goals □ □ □ □ □ □ □ □ □ □Other: □ □ □ □ □ □ □ □ □ □

5114-20160421-289751CLDISQST 05/16