Client Questionnaire

Date* Home Address* City* State* Zip*

Client 1

Number of Children

CHILD 1

Full Name

Date of Birth

CHILD 2

Full Name

Date of Birth

CHILD 3

Full Name

Date of Birth

CHILD 4

Full Name

Date of Birth

CHILD 5

Full Name

Date of Birth

CHILD 6

Full Name

Date of Birth

Client 1 Full Name* Birth City Birth State* Date of Birth Occupation* Employer* Work Address City State Zip Cell* Work Phone Fax no. Home Phone* Email* Do you want to add a second client? Yes No

Client 2

Client 2 Full Name* Birth City Birth State* Date of Birth Occupation* Employer* Work Address City State Zip Cell* Work Phone Fax no. Home Phone* Email*

Please provide approximate total amounts for items listed below:

Best Estimates:

ASSETS:

Residence - Market Value Cash, Savings, CDs, etc. Securities - Stocks, Bonds, Mutual Funds Other - Tax Shelter, Real Estate, Personal IRA, Pension, 401k & Retirements

LIABILITIES

Short Term Long Term Last Year's Tax Payment Annual Living Expenses

GROSS INCOME

Client 1 Client 2 What are your most important concerns (e.g.: Taxes, Inflation, Income, Retirement, Education, Budgeting, etc.)? What are your long-term & short-term financial goals?*

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An investor without investment objectives is like a traveler without a destination.

Ralph Seger

Timeless Wealth Advisors

Client Questionnaire

Client 1

CHILD 1

CHILD 2

CHILD 3

CHILD 4

CHILD 5

CHILD 6

Client 2

ASSETS:

LIABILITIES

GROSS INCOME

Timeless Wealth Advisors

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