Burkett Financial Services, LLC: Confidential Questionnaire

BURKETT FINANCIAL SERVICES, LLC
CONFIDENTIAL QUESTIONNAIRE
CLIENT NAME (1): CLIENT NAME (2):

Home Address: Home Address:
City, State, Zip: City, State, Zip:
Home Phone: Home Phone:
Work Phone: Work Phone:
Fax (Home or Work): Fax (Home or Work):
E-mail: E-mail:
Social Security #: Social Security #:
Birthdate: Birthdate:
How did you hear about us?

Contact me by: E-mail or Telephone
FAMILY MEMBERS (Please list children and other dependents)

Name Relationship Date of Birth Social Security # City and State
Client Employer (1): Client Employer (2):

Title/Job: Title/Job:
Years with employer: Years with employer:
Employment changes: Employment changes:
Age at retirement: Age at retirement:
Salary: Salary:
Self Employment Income: Self Employment Income:
Bonus/Commissions: Bonus/Commissions:
Social Security: Social Security:
Rental Income: Rental Income:
Retirement Income*: Retirement Income*:
Other Earned Income: Other Earned Income:
*If pension income, please describe any survivorship options. You may wish to attach a separate page.
X:\1\2007\BFS\Inquiry Folder\Data Questionnaire.doc

Yes No
Do you plan to make any extraordinary financial changes in the next five years?
Do you expect an inheritance? If yes, how much
Do you have a:
Will
Durable Power of Attorney
Healthcare Power of Attorney
Living Will
Any Type of Trust, i.e. ILIT, QTIP, Revocable
Date of original execution?
Date of any amendments?
Do you plan to pay for any education for children, grandchildren, yourself or others?
Are your parents or adult children dependent on you for support?
Have you ever been declined for any type of insurance? If so, what type and when:
Do you have any of the following insurance policies:

Homeowners
Automobile Policy – Business or Personal
Umbrella/Liability Policy – Business or Personal
Health – Group or Individual
Disability – Group or Individual
Long Term Care – Group or Individual
Life Insurance Policy – Cirlce Type: Term, Variable, Universal, Whole Life
Do you own a business?
Do you save systematically?
Are you satisfied with your financial progress?
In order of importance, what are your three most critical goals?
Please comment on the advice you seek
If you have one of the following advisors, please describe your professional relationship with each (Circle
your level or check N/A):

Satisfaction Rating
Very Not
Advisor Dissatisfied Satisfied Applicable
Financial Planner 1 2 3 4 5
Accountant 1 2 3 4 5
Investment Advisor 1 2 3 4 5
Attorney 1 2 3 4 5
Insurance Agent 1 2 3 4 5
Banker 1 2 3 4 5
Trustee 1 2 3 4 5
How much do you think the following affects portfolio performance?
Portfolio Allocation – Cash vs. bonds vs. stocks %
Investment Selection – Which stocks/ bonds to buy %
Market Timing – Getting into and out of the market %
How do you feel when the stock market fluctuates?
How did you select and determine the current allocations in your portfolio?
What do you think the average annual rates of return for inflation and the stock market have been since 1970?
What do you believe is a reasonable rate of return on your investments?
Assets Approximate Cost or Husband (H),

Market Tax Wife (W)
Value Basis or Joint (J)

Cash:
Checking Accounts
Savings & Money Market Accounts
Certificate of Deposits
U.S. Government & Corporate Bonds
Municipal Bonds
Deferred Annuities
Insurance-Cash Surrender Value
Mutual Funds:
Equity:
Bonds:
Balanced:
Individual Stocks (owned directly):

______________________
_____________________
_____________________
Rental Property & Land:

Location _____________
Location _____________
Ventures or Businesses:
_________________
_________________
Retirement Accounts:
Profit Sharing Plans
Savings Plans
Individual Retirement Accounts (IRA)
_________________
Personal & Other:

Personal Residence
Second Residence
Personal Property (Furniture, etc)
Jewelry & Art
Autos, RV's & Boats
Other Assets Not Identified:

______________________
______________________
______________________
Total Assets $
ASSETS & LIABILITIES (Continued)

Original Date Term Remaining
Loan of of Principal Monthly Person Interest
Liabilities Amount Loan Loan Balance Payment Liable Rate
Mortgages
________________
________________
Home Equity Loans
________________
________________
Investment Loans
________________
________________
Auto Loans
________________
________________
Credit Cards
________________
________________
Personal Loans
________________
________________
Auto Leases
________________
________________
Other
________________
________________
Total Liabilities $

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BURKETT FINANCIAL SERVICES, LLC

CLIENT NAME (1): CLIENT NAME (2):

How did you hear about us?

FAMILY MEMBERS (Please list children and other dependents)

Client Employer (1): Client Employer (2):

X:\1\2007\BFS\Inquiry Folder\Data Questionnaire.doc

Do you expect an inheritance? If yes, how much

Are your parents or adult children dependent on you for support?

Do you have any of the following insurance policies:

Do you own a business?

Do you save systematically?

Are you satisfied with your financial progress?

In order of importance, what are your three most critical goals?

Please comment on the advice you seek

X:\1\2007\BFS\Inquiry Folder\Data Questionnaire.doc

How much do you think the following affects portfolio performance?

Portfolio Allocation – Cash vs. bonds vs. stocks %

Investment Selection – Which stocks/ bonds to buy %

Market Timing – Getting into and out of the market %

How do you feel when the stock market fluctuates?

What do you believe is a reasonable rate of return on your investments?

Assets Approximate Cost or Husband (H),

X:\1\2007\BFS\Inquiry Folder\Data Questionnaire.doc

Individual Stocks (owned directly):

Rental Property & Land:

Personal & Other:

Other Assets Not Identified:

ASSETS & LIABILITIES (Continued)

X:\1\2007\BFS\Inquiry Folder\Data Questionnaire.doc

X:\1\2007\BFS\Inquiry Folder\Data Questionnaire.doc

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