Financial & Estate Planning Questionnaire

FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Midwestern Financial Group

The answers to the questions in this packet provide Midwestern Financial Group (MFG) with the starting point necessary to improve your financial situation. In order to provide the best client service possible, we ask that the following pages be completed to the fullest.

Included in this packet is a form meant to collect information about your ASSETS and LIABILITIES. Information about both of these items will improve the manager-client relationship and asset allocation for each individual.

Confidentiality Notice: Midwestern Financial Group adheres to the CFA Institute’s Asset Manager Code of Conduct and is therefore prohibited from sharing information collected. The Asset Manager Code of Conduct contains an assurance of the Manager’s loyalty to clients and strict standards regarding the investment process and actions. The code reads:

Manager Must: Preserve the confidentiality of information communicated by clients within the scope of the Manager-client relationship.

Midwestern Financial, LLC
332 S. Linn Street Suite 25
Iowa City, IA 52240

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Introduction

Included in this packet is a form meant to collect information about your ASSETS and LIABILITIES. Information about both of these items will improve the manager-client relationship and asset allocation for each individual.

Confidentiality Notice: Midwestern Financial Group adheres to the CFA Institute's Asset Manager Code of Conduct and is therefore prohibited from sharing information collected. The Asset Manager Code of Conduct contains an assurance of the Manager's loyalty to clients and strict standards regarding the investment process and actions. The code reads:

Manager Must: Preserve the confidentiality of information communicated by clients within the scope of the Manager–client relationship.

By signing below, you acknowledge that all information contained within this packet is accurate.

Print Name: *

Signature: *

Date: *

Print Name (Spouse):

Signature (Spouse):

Date (Spouse):

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Client Information

Name: *

Social Security Number: *

Date of Birth: *

Occupation: *

Spouse Name:

Spouse Social Security Number:

Spouse Date of Birth:

Spouse Occupation:

Home Phone: *

Business Phone:

Business Fax:

Mobile: *

Spouse Mobile:

Primary Address: *

City: *

State: *

ZIP Code: *

Email Address: *

Spouse Email:

How do you prefer we contact you? *

Children Information

Child 1:

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Estate Information

Do you and your spouse presently have wills? *

If so, when were they drafted or most recently revised?

Do they reflect your current circumstances and goals? *

Do you have a living will? *

Executor Information

Who has been named executor in your will?

Executor of Spouse's will:

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

INVESTMENT ASSETS

List All: Checking, Savings, Investment Accounts (including IRA, 401K and Pension Plans.)
Please note, you may simply provide us with copies of your most recent statements and we will complete this section for you.

Institution	Type of Account	Account Owner	Market Value

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Real Estate and Business Interests

Description	Date Acquired	Taxable Income	Annual Cash Flow	Cost (Tax Basis)	Estimated Value

Investment Properties

Description	Date Acquired	Taxable Income	Annual Cash Flow	Cost (Tax Basis)	Estimated Value

Business, General/Limited Partnership or LLC Interests

Description	Date Acquired	Taxable Income	Annual Cash Flow	Cost (Tax Basis)	Estimated Value

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Liabilities

Description	Date Borrowed	Term	Balance Due	Monthly Payment	Interest Rate

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

INCOME AND EXPENSES

Annual Income	You	Spouse	Total
Salary
Income from business (self-employed)
Net Income from real estate
Dividends
Interest
Trust Income
Child support/alimony received
Social Security
Other
Total Income

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

ANNUAL EXPENSES

Annual Expenses	Amount
Income Taxes (Federal, State, Local)
Real Estate Taxes
Homeowner's Insurance
Utilities (gas, electric, water, phone, cable)
Food
Clothing
Medical/Dental
Insurance (auto, life, health, disability)
Transportation (auto payments, gas, repairs)
Entertainment/Vacations
Gifts/Contributions
Education
Alimony/Child Support
Other
Total Expenses

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

INSURANCE

Life Insurance

Owner	Insured	Beneficiary	Type	Face Amount	Annual Premium

Disability Insurance

Owner	Insured	Beneficiary	Type	Face Amount	Annual Premium

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

Long-Term Care Insurance

Owner	Insured	Beneficiary	Type	Face Amount	Annual Premium

Other Insurance

Owner	Insured	Beneficiary	Type	Face Amount	Annual Premium

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

FINANCIAL GOALS

What are your short-term financial goals (1-3 years)?

What are your intermediate-term financial goals (3-10 years)?

What are your long-term financial goals (10+ years)?

At what age do you plan to retire?

What is your desired annual retirement income?

Are you concerned about providing for your children's education?

Are you concerned about providing for your parents or other relatives?

Are you concerned about leaving an inheritance?

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FINANCIAL AND ESTATE PLANNING QUESTIONNAIRE

RISK TOLERANCE

How would you describe your risk tolerance?

How would you react to a 20% decline in your portfolio value?

What is your investment time horizon?

What percentage of your portfolio are you comfortable investing in stocks?

Additional Comments or Questions:

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