“MPS LORIA continually enhances our services to meet the ever changing needs of our clients.” Questionnaire General Information: Your Name Date of Birth Spouse Name (co-client) Spouse Date of Birth Your EmploymentSelf-EmployedCompany OwnerEmployeeRetired Company Name Occupation Years with Company Spouse EmploymentSelf-EmployedCompany OwnerEmployeeRetired Spouse Company Name Spouse Occupation Spouse Years with Company Child 1 Name Date of Birth Child 2 Name Date of Birth Child 3 Name Date of Birth Child 4 Name Date of Birth Assets: Banks Accounts Account Name Checking 1 Owner Balance Checking 2 Owner Balance Savings 1 Owner Balance Savings 2 Owner Balance Other Owner Balance Taxable Accounts (please provide statements) Account Name Company Owner Balance Account Name Company Owner Balance Account Name Company Owner Balance Account Name Company Owner Balance Account Name Company Owner Balance Account Name Company Owner Balance Business Ownership Business Name Owner Business Type Appraisal (your share) Business Name Owner Business Type Appraisal (your share) Business Name Owner Business Type Appraisal (your share) Business Name Owner Business Type Appraisal (your share) Do you plan to sell your business to create retirement assets?yesno If yes, in what approximate year? Desired annual growth rate of business: Retirement Accounts (401(k), 403(b), IRA, SEP-IRA, Simple IRA) Account Name Company Owner Balance Account Name Company Owner Balance Account Name Company Owner Balance Assets Held for Education (529 Plan, Prepaid Tuition, Custodial Account) Account Name Type Owner Beneficiary Balance Account Name Type Owner Beneficiary Balance Account Name Type Owner Beneficiary Balance Account Name Type Owner Beneficiary Balance Account Name Type Owner Beneficiary Balance Liabilities Mortgages Personal Balance Remaining Term Remaining Interest Rate Vacation Home Balance Remaining Term Remaining Interest Rate Investment Property 1 Balance Remaining Term Remaining Interest Rate Investment Property 2 Balance Remaining Term Remaining Interest Rate Other Balance Remaining Term Remaining Interest Rate Home Equity Line of Credit: Amount Available: Other Debt Debt Balance Interest Rate Vehicle Balance Interest Rate Vehicle Balance Interest Rate All Credit Cards Balance Interest Rate Student Loans Balance Interest Rate Other Balance Interest Rate Income and Retirement Analysis Your current annual income Spouse current annual income At what age do you expect to retire? At what age does your spouse expect to retire? How much do you contribute to your retirement plans each year? How much does your spouse contribute to their retirement plans each year? Any additional annual savings? Desired annual income goal at retirement Pensions Client Name Monthly Amount at Start Age at Start Inflation COLAyesno Client Name Monthly Amount at Start Age at Start Inflation COLAyesno Client Name Monthly Amount at Start Age at Start Inflation COLAyesno Pensions - What payout option does this pension represent? Single LifeJoint and 50% SurvivorJoint and 100% Survivor Name Applicable Pension Social Security Client Name Age to Start Payments Estimated Monthly Payments Client Name Age to Start Payments Estimated Monthly Payments Other Expenses Anticipated Expense Estimated dollar amount of expense What year expense applied Anticipated Expense Estimated dollar amount of expense What year expense applied Insurance Analysis Life Insurance: Term Policies Face Value Insured Name Group or Individual Term Remaining Premium/Yr Life Insurance: Permanent Policies Face Value Type Year Purchased Insured Name Cash Value Premium/Yr Face Value Type Year Purchased Insured Name Cash Value Premium/Yr Face Value Type Year Purchased Insured Name Cash Value Premium/Yr Face Value Type Year Purchased Insured Name Cash Value Premium/Yr Long Term Disability Insurance Name of Account Monthly Benefit Group or Individual Premium/Yr Name of Account Monthly Benefit Group or Individual Premium/Yr Name of Account Monthly Benefit Group or Individual Premium/Yr Name of Account Monthly Benefit Group or Individual Premium/Yr Long Term Care Insurance Name Daily Benefit Inflation Rideryesno Term Premium/Yr Name Daily Benefit Inflation Rideryesno Term Premium/Yr Name Daily Benefit Inflation Rideryesno Term Premium/Yr Name Daily Benefit Inflation Rideryesno Term Premium/Yr Estate Planning Do you have update wills?yesno Do you have powers of attorney for healthcare?yesno Do you have executed healthcare proxies?yesno Do you have powers of attorney for property?yesno Have you established any trust documents?yesno When were these documents last updated? Notes
