Questionnaire – Wadsworth Financial Consulting

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Client Login

Charting Your Course For A Smooth Sailing Retirement

We are looking forward to getting together with you. If you have any questions or require special assistance prior to your visit, please call our office at 410.850.4121.

Please bring the following items to your first visit with us:
ALL investment statements, including bank, IRA, 401(k), annuity, brokerage accounts, mortgage statements, and prior year tax return.

Step 1 of 13

Contact Information
Name*
First Last
Nickname
Date of Birth*
Working At/Retired From*
Current/Former Occupation*
Retired*
Home Phone
Cell Phone*
Email Address*
Spouse Information
Spouse Name
First Last
Spouse Nickname
Spouse Date of Birth
Working At/Retired From
Current/Former Occupation
Retired
Home Phone
Cell Phone
Email Address
Primary Address*
Street Address Address Line 2 City State ZIP Code
Were you referred to us?*
By whom?

Family
Child 1
Age
Number of Grandchildren
Grandchildren's Ages
Child 2
Age
Number of Grandchildren
Grandchildren's Ages
Child 3
Age
Number of Grandchildren
Grandchildren's Ages
Child 4
Age
Number of Grandchildren
Grandchildren's Ages
Child 5
Age
Number of Grandchildren
Grandchildren's Ages
Who are your trustees and/or executor?*

Legal Items
Which of the following legal documents do you have in place?*
- Will
- Power of Attorney (POA) Assets
- Power of Attorney (POA) Health
- Living Will
- Living Trust
Date Last Updated

Additional Items
Which of the following legal do you have in place?*
- Umbrella Policy
- Long-Term Care Insurancd
Have you prepaid for funeral?*
Death Benefit Type:*
Life Insurance:*
Life Insurance:

Cash Flow
Please list monthly income from each source:
Husband
Social Security
Pension
(Survivor Options)
Wages
Other Income
Are these amounts net or gross?
Wife
Social Security
Pension
(Survivor Options)
Wages
Other Income
Are these amounts net or gross?
How much are your monthly expenses?*
Here are some common expenses: Mortgage, Food, Gas, Car Loan, Insurance, Utilities Gifts/Donations, Medical, Taxes, Social Security, etc.

Cash Flow Cont'd
Is your current cash flow sufficient and comfortable?*
Do you take any withdrawals from your retirement savings to meet your current budget?*
Do you anticipate any significant changes in cash flow?*
Are you planning any major lifestyle changes?*
Do you forsee any large purchases greater than $50,000 within the next 3 years?*
Do you contribute to charity?*

Life
In the future I expect to: (Please check all that apply.)*
- Buy a home
- Sell a home
- Improve a home
- Retire
- Care for a parent
- Start/expand a business
- Pay off a debt
- Start a part-time job
- Help fund education costs for a family member
- Sell a property
- Receive an inheritance
- Purchase a property
- Other
Other

Assets
Please answer which accounts you currently hold and note the approximate value OR bring the latest statement in for your visit.
Bank / Credit Union Accounts*
Approximate Value
CDs*
Approximate Value
Mutual Funds / Stocks / Bonds*
Approximate Value
Brokerage Accounts*
Approximate Value
Business Interest*
Approximate Value
Annuities*
Approximate Value
Current Contributions*
Approximate Value
Retirement Accounts from Work*
Approximate Value
IRAs/401(k)/403(b)/Keoghs/TSAs Life Insurance*
Approximate Value
Long Term Care Insurance*
Approximate Value
Promissory Notes / Contract for Deed*
Approximate Value
Other Assets*
Approximate Value

Assets Cont'd
Property
Home Value*
Balance Owed*
Payment*
Pay Off Date*
Auto(s) & Personal Property*
Balance Owed*
Payment*
Pay Off Date*
Rental/Additional Properties
Balance Owed
Payment
Pay Off Date*

Additional Information
If you are not already retired, when do you want to retire?*
MM slash DD slash YYYY
What is your after-tax retirement income goal?*
How did you acquire your wealth?*
Who else do you rely on for financial advice and decisions?*
If something were to happen to you tomorrow, do you want to plan for loved ones or charity?*
Please pick the top two for your retirement “nest egg” money.*
- Safety
- Liquidity
- Growth
- Income
- Family Longevity
Why?*
Client Life Expectancy
Spouse Life Expectancy

Concerns
Which of the following are your top three concerns?*
- Losing too much money in the stock market
- Need direction with a 401(k) and/or IRA accounts
- Considering retirement and not sure if I/we can afford to
- Leaving a legacy to children and/or grandchildren
- Concerned about losing life savings due to a catastrophic illness
- Outliving nest egg
- Uncertainty about the stock market
- Avoid paying too much in taxes
- Not having a reliable income plan for retirement
- Other
Other

Objectives
Which of the following describes your risk tolerance when it comes to retirement assets?*
What are your financial objectives? (check all that apply)*
- Income Now/Later
- Reduce Risk
- Growth Potential
- Reduce Taxes
- Reduce Fees
- Pass to Beneficiaries
- Other
Other

Client Signatures
Client Name(s):*
By checking this box, I am approving that the above named individual(s) certifies that the information contained herein is accurate to the best of his/her knowledge and acknowledges that such information will be relied upon by your agent to provide financial recommendations*
- Approve

Contact Us

Phone: 410-850-4121
Fax: 410-975-5918
jeff@wadsworthfc.com
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Our Location

65 Old Solomons Island Road
Suite 108
Annapolis, MD 21401
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Disclosures

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Securities offered only by duly registered individuals through Madison Avenue Securities, LLC ("MAS"), member FINRA/SIPC. Investment advisory products and services made available through AE Wealth Management, LLC (AEWM), a Registered Investment Adviser. MAS and Wadsworth Financial Consulting, LLC, are not affiliated companies. Insurance products are offered through the insurance business Wadsworth Financial Consulting, LLC. Wadsworth Financial Consulting, LLC, is [also] an Investment Advisory practice that offers products and services through AE Wealth Management, LLC (AEWM), a Registered Investment Adviser. AEWM does not offer insurance products. The insurance products offered by Wadsworth Financial Consulting, LLC, are not subject to Investment Advisor requirements. AEWM and Wadsworth Financial Consulting, LLC are not affiliated companies.

Investing involves risk, including the potential loss of principal. No investment strategy can guarantee a profit or protect against loss in periods of declining values. None of the information contained on this website shall constitute an offer to sell or solicit any offer to buy a security or any insurance product. Neither the firm nor its agents or representatives may give tax or legal advice. Individuals should consult with a qualified professional for guidance before making any purchasing decisions.

Any references to protection benefits, safety, security, steady and reliable income, or lifetime income streams on this website refer only to fixed insurance products. They do not refer, in any way, to securities or investment advisory products. Annuity guarantees are backed by the financial strength and claims-paying ability of the issuing insurance company. Annuities are insurance products that may be subject to fees, surrender charges and holding periods which vary by insurance company. Annuities are not FDIC insured.

The information and opinions contained in any of the material requested from this website are provided by third parties and have been obtained from sources believed to be reliable, but accuracy and completeness cannot be guaranteed. They are given for informational purposes only and are not a solicitation to buy or sell any of the products mentioned. The information is not intended to be used as the sole basis for financial decisions, nor should it be construed as advice designed to meet the particular needs of an individual's situation. 11897464 - 10/23

Charting Your Course For A Smooth Sailing Retirement

Step 1 of 13

Contact Information

Spouse Information

Family

Legal Items

Additional Items

Cash Flow

Husband

Wife

Cash Flow Cont'd

Life

Assets

Assets Cont'd

Property

Additional Information

Concerns

Objectives

Client Signatures

Contact Us

Our Location

Disclosures

Check Us Out