confidential wealthcare questionnaire - family wealth · pdf file ·...

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Confidential WealthcareQuestionnaire

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One Greentree Centre, Suite 300, Marlton, NJ 0805(856) 988-7722 • www.familywealth.info

http://www.familywealth.info

Personal Data

Client A Client BName NameDate of Birth Date of BirthSS # SS #Address AddressCity CityState Zip State ZipHome Phone Home PhoneCell Phone Cell PhoneEmail EmailFax Fax

Family Members (please list children and other dependants)Name Relationship Date of Birth Dependant Resides

y Ny NY Ny NY N

OccupationClient A Client BJob Title Job TitleEmployer EmployerAddress AddressCity State Zip City State ZipPhone Ext. Phone Ext.Fax Email Fax EmailNumber of Years with this employer Number of Years with this employerWhen do you plan to retire? When do you plan to retire?

IncomeClient A Client B

Monthly Annual Monthly AnnualSalary $ $ Salary $ $Self-employment $ $ Self Employment $ $Bonus/Commissions $ $ Bonus/Commissions $ $Interest & Dividends $ $ Interest & Dividends $ $Pensions & Annuities $ $ Pensions & Annuities $ $Social Security $ $ Social Security $ $Alimony $ $ Alimony $ $Rental Property (Net) $ $ Rental Property (Net) $ $Other $ $ Other $ $Total Income $ $ Total Income $ $

, .

Tax & Estate Planning

Who prepares your tax return? _

Name-------------------

Phone _

Fax-------------------City State _

Do you have estate planning documents?

Zip _ Email------------------

Year Drafted

0 Wills

0 Living Trusts

0 Powers of Attorney

0 Living Wills

0 Other Documents

State Drafted

Financial Opinions/PreferencesOf the following statements, summarize your attitudes or beliefs using a scale of 1-5.

Client A Client B 1=Most True. 5=Least True

1would rather work longer than reduce my standard of living in retirement.

1 feel that I/we can reduce our current living expenses to save more for the future ifneeded.

I am more concerned about protecting my assets than about growth.

I prefer the ease of mutual funds over individual securities.

I am comfortable with investments that promise slow, long term appreciation and growth.

I feel comfortable with aggressive growth investments.

My immediate concern is for income rather than growth opportunities.

I need to focus my investment efforts on building cash reserves.

I don't brood over bad investment decisions I've made.

I am optimistic about my financial future.

I make investment decisions comfortably and quickly.

I prefer predictable, steady return on my investments, even if the return is low.

How were your current investment assets selected? _

AdvisorsName Firm Phone

Accountant

Attorney

Insurance Agent (life/health)

Insurance Agent (home/auto)

Stockbroker

Family ProtectionIncome Need Client SpouseWhat percentage of your income would youlike to protect for the family? % %

Income to be protected $ $

How many years to protect this income? yrs yrs

Net rate ofretum % %

Capital sum needed to fund family income needs $ $Cash Needs

Outstanding loans (mortgages/others) $ $

Immediate cash needs at death (funeral, etc.) $ $

Charitable bequests $ $

Total $ $

Life InsuranceCurrent Current

Insurance Insured Net Death Annual Net CashPolicy (HIW) Owner Beneficiary Benefit Premium Value

DisabilityInsurancePolicy

Insured(HIW) Type

MonthlyBenefit

AnnualPremium

EliminationPeriod

BenefitPeriod COLA

Long Term CareInsurance InsuredPolicy (HIW) Owner

DailyBenefit

AnnualPremium

EliminationPeriod (Days)

BenefitPeriod (Years) COLA

Discovery Questions: Please answer in detail

What do you want this life insurance to do for you?

How did you arrive at the amount of life insurance you have?

From whom did you buy your last policy?

Are you obligated to do business with anyone else?

Have your special hobbies or health conditions affected your insurance planning?

Are you and family members covered by health insurance?

Will you be caring for elderly parents?

In the future, will you receive any income (monthly or lump sum) from any plan, family trust or inheritance?

(;eneralInsurancePolicy Type

Liability

Homeowner's

Medical

Auto Values $ _

Policy Name Policy Benefit Annual Premium

Assets(If you have this in information available in another format, please omit this and attach necessary information.)Bank Accounts Checking (C), Savings (8), Money Market (MM)Bank Name C S MM Ownership Average Balance

DOD

DOD

DOD

DOD

DOD

CD'sInstitution Interest Rate Maturity Date Ownership Average Balance

/ / $----/ / $----/ / $----/ / $----

Investments

Type of Investment(Pers/IRA, 40 I K, etc.) Owner Institution Market Value

Financial PrioritiesAssumptionGross Expected Rate of Return

Expected Rate of Inflation

Net Rate of Return

----_%

----_%

----_%

Please provide copies of your most recent statements.

Do you have a pension?Client A 0 NoClient BONo

DYes - estimated monthly benefit is $ at age . COLA? 0 Yes 0 NoDYes - estimated monthly benefit is $ at age . COLA? 0 Yes 0 No

Personal PropertyEstimated Value

Primary Residence

Furnishings (Liquidation Value)

Vehicle

Vehicle

Rental Property

Other

Interest Rate

Personal Liabilities

Credit Cards Avg. Monthly Payment

-----_% $

-----_% $

-----_% $-_ ..._-_% $

-----_% $. --- % $

Current Balance

Debts(Residence, Auto. Business. School. etc.)

Asset Allocation

Terms Interest Rate Payment

% $

% $

% $

% $

% $

% $

Aprrox. Balance

Determining you needs, wants and characteristics as an investor is important when it comes to building a portfolio you

will be comfortable with. After reviewing this questionnaire, you may have a better understanding of the type of

investor you are and what kinds of investments may be best suited to meet your goals.

Instructions: Answer the following questions. Then add your scores for each question and match your total score with

the corresponding portfolio type shown at the end ofthe questionnaire. Please consult with your investment

representative to make sure the results are consistent with your needs and investment personality, and for help in

selecting specific investment choices that are suitable for you.

Time Horizon

1.In how many years do you expect to begin making withdrawals from your investment account?

o Immediately (1 point)

o Within the next 3 years (3 points)

o 3 to 6 years (6 points)



o More than 15 years (15 points)

2. How long do you expect withdrawals from your investment account to continue?

1expect to take a lump sum (I point)

o Under 3 years (3 points)




o More than 15 years (15 points)

Risk Tolerance

3. Which statement best describes your investment objective for your investment account?

o 1am looking for stability of my account balance and want to avoid any losses. (I point)

o 1am looking for stability of my account, but 1 can accept a low to moderate amount of fluctuation in

my account if! can have more growth potential. (3 points)

o 1am focused on growth. 1 am not concerned about moderate fluctuations each year. (6 points)

o 1am focused on account growth, and 1 am willing to accept a higher level of risk for higher returns. (9 points)

o 1am seeking the most growth possible, and I am not concerned about fluctuations in the value of my account. (12 points)

o 1am not sure what my investment objective should be. (3 points)

4. Which statement best describes your approach as an investor?

o 1am very cautious about taking risks, and 1want to avoid losses in my account. (I point)

o 1am somewhat cautious about taking risks, and 1 can handle relatively smal1losses in my account

occasional1y. (3 points)

o 1am mixed between taking risks that are general1y associated with greater account growth

potential and the desire to minimize short-term losses in my account. (6 points)

o 1am open to taking some risks for growth potential. 1am less concerned about short-term (less

than one year) losses or gains; 1am looking more for long-term growth in my investments. (9points)

o 1am a risk taker, and want to maximize the growth of my account over the next decade or longer,

and am not concerned about short time-term losses. (12 points)

o 1am not sure what type of investor 1am. (3 points)

I .

5. Generally, I'm very impatient during unfavorable market conditions and will usually change my mind often.

o I strongly agree (I point)

o I agree (3 points)

o I somewhat agree (5 points)

o I disagree (7 points)

o I strongly disagree (II points)

o I'm not sure (3 points)

6. Consider the following ranges of possible returns over a one-year period. Which set of possibilities are

you most comfortable with as it relates to your investment account?

o A (I point)

o B (2 points)

o C (3 points)

o 0 (4 points)Trial User

o E (5 points)

A. Average 6.4%B. Average 7.8%-C. Average 9.2%--D. Average 10.2%-E. Average 11.1%

-2.0% r-5.6% r

-10.2% I

-16.4% I

-22.5%

--17.3%22.3%

30.8%38.9%

46.9%

The ranges in the table are based on historical returns of different allocations of stocks and bonds, as represented byappropriate indices, over the last 76 years. The table reflects the range of returns an investor could have experienced95 percent of the time in anyone year. These ranges are intendedfor the purpose of assessing risk tolerance anddetermining investment suitability. They do not represent the actual historical returns of any particular investmentfimd or vehicle. nor are they a prediction or guarantee offuture investment peiformance.

7. The chart below shows possible growth of $40,000 over a five-year period for a series of different

investment strategies. Which of the five scenarios are you most comfortable with as an investor?

o A (I point)

o B (2 points)

o C (3 points)

o 0 (4 points)

o E (5 points)

A. Average $54,624 -B. Average $57,123-C. Average $61,998 -D. Average $65,126-E. Average $67,646 -

$44,476$41,376$38,024 I

$32,937 r$27,514

--$73,30180,084

88,148$98,855

$112,629

The ranges in the table are based on historical returns of different allocations of stocks and bond;'. as represented by appropriateindices. over the last 76 years. The dollar amounts illustrate what could happen 95 percent of the time after five years if aninvestor had an initial investment (? ($40, 000. These ranges are intended for the purpose of assessing risk tolerance anddetermining investment suitability. They do not represent the actual historical returns of any particular investment fund orvehicle. nor are they a prediction or guarantee of future investment performance.

8. What would you do if you heard on the news or read in the newspaper that the U.S. stock market suddenly dropped 20%

o I would change my strategy to something with less volatility. This kind of market volatility makes me

very nervous - I don't want to be exposed to this type of risk again. (I point)

o I would move most of my account into something a bit less risky. This kind of market volatility makes me

nervous, but I would consider getting back into stock funds when it has quieted down. (4 points)

o I would probably move half of my stock portfolio balance into something with less market volatility, such

as cash or bonds. This kind of market volatility makes me a little nervous, so I would rather reduce some

of my stock exposure until the market has quieted down. (7 points)

o I would stick with my investments, but I would probably worry about meeting my investment goals and

watch my account balance very closely. (10 points)

o I would stick with my investment selections and would not make any changes. I have enough time and

patience to ride it out. (13 points)

o I don't know what I would do. (4 points)

Total Points

Scoring and Corresponding Model Portfolio

Enter the score for each question next to the appropriate number.

1.

2.

3.

4.5.

6.7.

8.

Scores between:

8 and 18 >

19and38>

39 and 58>

59 and 78>

79 and 88>

Conservative

Moderately Conservative

Moderate

Moderately Aggressive

Aggressive

Aggressive

Moderately Aggressive

Moderate

Moderately Conservative

ConservaliVt::

, .SavingsTo estimate the likelihood of meeting your goals, we need to know how much you are saving each year. If you do not have

detailed information for items like matching employer contributions, matches on deterred compensation, etc., please provide your

best estimate for amount. Please provide the total amount and circle either "annually" or "monthly."

Client A

40 Ik, SEP, 403b, IRA, Deferred Compensation, etc.

Roth IRA

Taxable/Other Savings

Client B

40 I k, SEP, 403b, IRA, Deferred Compensation, etc.

Roth IRA

Taxable/Other Savings

Goals

Amount: $ (annually/monthly)






Wealthcare is different from traditional financial planning and wealth management services because it

considers all of the goals you have and what you ideally would like to achieve. Please complete the

following questions:

I. Ideally, I would like to retire at age , but if needed to meet other more important financial goals, J

would be willing to work to age . (Input "now" if already retired)

2. My spouse will retire at the same time as I will: Yes or No

(fno, my spouse would ideally like to retire are age , but if needed to meet other more important

financial goals, I would be willing to work to age . (Input "now" if already retired)

3. If possible, I would like to leave an estate worth at least $ , but would be willing to

leave as little as $ ifnecessary to meet other more important goals.

4. How would you like us to estimate your retirement income needs? (check one)

o (would like you to estimate my retirement income needs based on my current income and your

estimates of what would be needed to maintain my lifestyle (do not select this option if already

retired, input your annual spending needs below) OR ...

o I would ideally retire on an annual retirement spending budget of$ , BUT in no

case less than $ _

5. Which best describes your attitude about Social Security: (check one)

o I would prefer not to be dependent on Social Security in retirement.

o J would like to include estimated Social Security benefits in our Wealthcare Plan.

6. OPTIONAL: I have other specific goals that I will need money for and would like to include these expenditures in

our Wealthcare Plan such as extraordinary travel, buy exotic car, vacation home, etc. (Do NOT include basic

retirement income goals, estate, or children's college educational goals.)

Description Annual Amt. Starting Age Ending Age Client

AorB

AorB

AorB

AorB

Growth Rate

PrioritiesYour Wealthcare Plan will be designed to help you have a high confidence level that your most important financial

goals will be achieved. To design the optimal set of the hundreds of potential choices, we need to prioritize your goals

to identify those alternatives that make the most sense for what you want to accomplish.

1. Investment Risk (volatility or risk of losing money) is something we all wish to avoid ifpossible. With Wealthcare,

we can often take less than our maximum tolerance for risk by making relatively minor modifications to our other

goals. I would be willing to do the following to design a plan that takes less risk than my maximum risk tolerance

indicates (check al\ that apply):

D Save $ more a year than I'm currently saving.

D Retire later than my ideal retirement.

D Leave a smaller estate than my ideal estate.

D Lower my retirement income to more modest levels.

D I'm comfortable with taking investment risk (based on my maximum tolerance) and I'd prefer to accept

that level of investment risk rather than modify any of these other goals.

2. Saving money is usually necessary to achieve your financial goals. However, it may also mean you are making

sacrifices in your current lifestyle to achieve future goals. Ifpossible, I would like to reduce my current annual savings

by $ a year so I can improve my current lifestyle. To meet this goal I would be willing to modify

the following goals (check all that apply):

D Take more risk than my maximum risk tolerance indicates.

D Retire later than my ideal retirement age.



D I'm comfortable with saving more than my ideal annual savings amount rather than modifY any of these

other goals.

...

3. When you plan to retire, it can have a significant impact on the probability of achieving yourfinancial goals because

it is the age when you stop saving and begin to withdraw from investments. To retire at my age, I would be wilIing to

-------------------- -----

I'I

modify the folIowing goals (check all that apply):


D Save $ _ more a year than I'm currently saving.

D Leave a smalIer estate than my ideal estate.


D Retiring at my ideal age isn't as important as these other goals, so I am comfortable delaying retirement to

a later age to avoid modifying these other goals.

4. Many people have charitable desires or wish to pass wealth on to their family to provide financial security. Doing

so can mean compromising other goals. To achieve my ideal estate or charitable goals, I would be willing to modify

the folIowing goals (check all that apply):



D Save $ more a year than I'm currently saving.


D While I'd like to achieve my goals, doing so isn't as important as these other objectives, so I'd be willing

to reduce my estate goal to avoid modifying these other goals.

5. Your lifestyle in retirement is dependent both on the resources you have available and your personal preferences.

Most people would like to have a comfortable retirement income and lifestyle. To maximize my retirement income, I

would be wilIing to modify the following goals (check alI that apply):



D Save more money than my ideal savings amount.


D I'd like to have a very comfortable retirement, but I would be willing to live a more modest lifestyle in

retirement rather than changing these other goals.

The undersigned acknowledges that the information contained in the Wealth care Questionnaire is true and accurate, to the best of his /herknowledge. The undersigned also acknowledges receipt of Mutual of Omaha Investor Services ADV Part II, has had the opportunity to review itand is fully aware of the content of Mutual of Omaha Investor Services for ADV Part II as filed with the Securities and Exchange Commission.

Client A _ Date _

Client B _ Date _

The Security and Exchange Commission requires that fidl disclosure of Martins V. Higgins' qualification, methods, fee and othervital business data be presented to potential users of the Wealthcare process in a governmentform called the ADV Part II Youshould always request an AD V Part II whenever you are considering employing an investment advisor or receiving advice. Readthe ADV Part II thoroughly and ask questions if you have any.