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Confidential Questionnaire

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For your convenience, this form can also be downloaded, printed and sent to us via fax or standard mail. Click here for the .pdf version.

Family Data
First Name:
 Last Name:
  
Spouse's First Name:
 Spouse's Last Name:
    
Address:
 City:
 State:
 Zip Code
Phone Number:
 Cell Phone:
 Email:
 
Your Date of Birth:
 Spouse's Date of Birth:
 Number of Children:
 
Employment Data
Current Occupation:
 Spouse Current Occupation:
  
Tell Us About Your Retirement Accounts:
  401-K IRA
  SEP Other
The above accounts are invested in:
  Bonds
  Annuities
  Other
Tell Us About Your Spouse's Retirement Accounts:
  401-K IRA
  SEP Other
The above accounts are invested in:
  Bonds
  Annuities
  Other
Do you anticipate needing your IRA for retirement income?
Are your IRA's your only source of income for retirement?  
Do you have or will you have a company pension or benefit for retirement?
In consideration of your net estate size, what do you estimate the value of your estate to be?
  Net worth over $2,000,000
Please Tell Us a Little About your Current Real Estate Holdings.
Do you own your personal residence? Yes No 
What year was it purchased?

Purchase Price:

Current Market Value:
Current Interest Rate:

Months remaining on mortgage:

Total Unpaid Balance:
Do you own a second home? Yes No

What year was it purchased?

Purchase Price:

Current Market Value:

Current Interest Rate:

Months remaining on mortgage:

Total Unpaid Balance:
Do you own a another home? Yes No
Year Purchased:

Purchase Price:

Current market value:
Current Interest Rate:

Months remaining on mortgage:

Total unpaid balance:
Do you own any commercial property? Yes No
Year Purchased:

Purchase Price:

Current market value:
Current Interest Rate:

Months remaining on mortgage:

Total unpaid balance:
Do you own any land? Yes No
Year Purchased:

Purchase Price:

Current market value:
Current Interest Rate:

Months remaining on mortgage:

Total unpaid balance:
Do you own any rental Property? Yes No
Year Purchased:

Purchase Price:

Current market value:
Current Interest Rate:

Months remaining on mortgage:

Total unpaid balance:
What is it you like most about your current Real Estate holdings?
Where do you anticipate your new Real Estate payment coming from?
Are there other issues you want coordinated with your Real Estate Purchase?
Please explain why you would like to use your IRA monies to purchase Real Estate.
What types of real estate are you interested in purchasing?
Commercial Second Home Condominium Rental Land Office Other

What is the location of the property you are interested in?

What is the planned purchase price?

What is the planned purchase date?
By checking this box, you affirm that the information provided in this questionnaire is accurate and true to the best of your knowledge.
Any additional comments or questions?
Your information is carried on our secure servers. We will not sell, distribute or otherwise mishandle your information. Your privacy is respected, protected and maintained by us. If you have chosen to fax this form and other required information, please send it to 630-232-7111.

 

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