Please be as accurate as possible in entering your information.

1. Tell me about you and your family:

   Name:		Date of Birth:	SSN:
   Single Married	Divorced Widow(er)	# of Children # of Grandchildren # of Other Dependents
   Spouse: Date of Birth: SSN:

   
   
2. How do you think I can help or what are your expectations from me?
   
   
3. What is your Gross Annual Income? $ .00
   

   	Yours	Spouses
   Salary	$ .00	$ .00
   Interest	$ .00	$ .00
   Dividends	$ .00	$ .00
   Rent	$ .00	$ .00
   Self-Employment	$ .00	$ .00
   Other	$ .00	$ .00
   Total	$ .00	$ .00

   
   
4. How much are you currently systematically investing or re-investing on a monthly basis?  $
   
   
5. How much do you currently want to invest?

   Lump Sum: $
   Systematically: $	per Week Two Weeks Month Quarter Six Months Year

   
   
6. Are you participating in any of the following:

   401(k) 403(b)

   457 Traditional IRA

Where you would like the results e-mailed to:

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of the client's collected financial data from this short demonstration.