Financial Planning Analysis Questionnaire Please enable JavaScript in your browser to complete this form.Your Information - Step 1 of 9Please fill out the following form no less than 4 business days prior to your appointment. Approximate values rounded to the nearest thousand can be used if you do not know the exact amount. You are not obligated to provide any information you don’t feel comfortable disclosing. However, having all your information allows us to better understand your personal situation and provide you with a more comprehensive plan. Integrity Financial Group, LLC takes the issue of privacy very seriously. We want to assure you that we protect the security and privacy of any information that you share with us. All information is kept strictly confidential and is not sold or shared. Name *FirstLastLayoutPhone *Email *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you are veteran?Please SelectYesNoLayoutOccupationAnnual Gross IncomeEmployerAnnual Net IncomeWhen do you plan to retire?NextSpouse's NameFirstLastLayoutSpouse's PhoneSpouse's EmailIs your spouse a veteran?Please SelectYesNoLayoutSpouse's OccupationSpouse's Annual Gross IncomeSpouse's EmployerSpouse's Annual Net IncomeWhen does your spouse plan to retire?PreviousNextLayoutNameName 2Name 3Name 4Name 5Name 6Name 7Name 8AgeAge 2Age 3Age 4Age 5Age 6Age 7Age 8Marital StatusPlease SelectMarriedNever MarriedDivorcedMarital Status 2Please SelectMarriedNever MarriedDivorcedMarital Status 3Please SelectMarriedNever MarriedDivorcedMarital Status 4Please SelectMarriedNever MarriedDivorcedMarital Status 5Please SelectMarriedNever MarriedDivorcedMarital Status 6Please SelectMarriedNever MarriedDivorcedMarital Status 7Please SelectMarriedNever MarriedDivorcedMarital Status 8Please SelectMarriedNever MarriedDivorcedHow many kids?How many kids? 2How many kids? 3How many kids? 4How many kids? 5How many kids? 6How many kids? 7How many kids? 8PreviousNextDo you have any of the following?WillTrustMedical DirectivePower of AttorneyWhat type of trust do you have?Please SelectRevocable/LivingIrrevocableWho helped you with your estate plan?Estate plans are typically done by attorneys. Please type the name of the attorney or let us know if you used an online service. What year was your estate plan completed?PreviousNextFinancial ConcernsPlease rate how concerned you are with the following topics on a scale of 0-5 with 0 being not concerned at all and 5 being extremely concerned.LayoutProtecting my assets. Selected Value: 0 Potential loss of income after passing of you or your spouse. Selected Value: 0 Having enough income in retirment. Selected Value: 0 Leaving maximum amount of assets to my heirs. Selected Value: 0 Approximate Monthly ExpensesApproximate Desired Income in RetirementPreviousNextBank Accounts (Non-IRA)Bank AccountsName of Bank2 Name of Bank3 Name of Bank4 Name of Bank5 Name of Bank6 Name of BankType of AccountType of Account 2Type of Account 3Type of Account 4Type of Account 5Type of Account 6Interest RateInterest Rate 2Interest Rate 3Interest Rate 4Interest Rate 5Interest Rate 6Approximate BalanceApproximate Balance 2Approximate Balance 3Approximate Balance 4Approximate Balance 5Approximate Balance 6IRAs & Other Retirement AccountsIRAs and Retirement AccountsCompany2 Company3 Company4 Company5 Company6 CompanyType of AccountType of Account 2Type of Account 3 Type of Account 4 Type of Account 5Type of Account 6 Approximate ValueApproximate Value 2Approximate Value 3Approximate Value 4Approximate Value 5Approximate Value 6Account HolderAccount Holder 2Account Holder 3Account Holder 4Account Holder 5Account Holder 6Stock and Bond CertificatesStock/BondsName of Stock/Bond2 Name of Stock/Bond3 Name of Stock/Bond4 Name of Stock/Bond5 Name of Stock/Bond6 Name of Stock/BondNumber of SharesNumber of Shares 2Number of Shares 3Number of Shares 4Number of Shares 5Number of Shares 6Approximate Value Approximate Value 2Approximate Value 3Approximate Value 4 Approximate Value 5Approximate Value 6Account HolderAccount Holder 2Account Holder 3Account Holder 4 Account Holder 5Account Holder 6 Mutual Funds/ Brokerage AccountsMutual Funds/ Brokerage AccountsFund/Brokerage Name2 Fund/Brokerage Name3 Fund/Brokerage Name4 Fund/Brokerage Name5 Fund/Brokerage Name6 Fund/Brokerage NameApproximate ValueApproximate Value 2Approximate Value 3Approximate Value 4Approximate Value 5 Approximate Value 6 Account HolderAccount Holder 2Account Holder 3 Account Holder 4Account Holder 5Account Holder 6NextLong Term Care InsuranceLTC InsuranceInsurance Company2 Insurance Company 3 Insurance Company 4 Insurance CompanyInsuredInsured 2Insured 3Insured 4Benefit AmountBenefit Amount 2Benefit Amount 3Benefit Amount 4Premium AmountPremium Amount 2Premium Amount 3Premium Amount 4Life InsuranceLife InsuranceInsurance Company2 Insurance Company3 Insurance Company4 Insurance CompanyInsuredInsured 2Insured 3Insured 4 Cash ValueCash Value 2Cash Value 3Cash Value 4Death BenefitDeath Benefit 2Death Benefit 3Death Benefit 4PreviousNextReal Estate & ResidenceReal Estate & ResidenceProperty Address2 Property Address3 Property Address4 Property Address5 Property AddressOriginal CostOriginal Cost 2Original Cost 3Original Cost 4Original Cost 5Current Market ValueCurrent Market Value 2Current Market Value 3Current Market Value 4Current Market Value 5Debt OwedDebt Owed 2Debt Owed 3Debt Owed 4Debt Owed 5Business/PartnershipsBusinesses/PartnershipsName of Partnership2 Name of Partnership3 Name of Partnership4 Name of Partnership5 Name of PartnershipType of InvestmentType of Investment 2Type of Investment 3Type of Investment 4Type of Investment 5Amount InvestedAmount Invested 2Amount Invested 3Amount Invested 4Amount Invested 5Market ValueMarket Value 2Market Value 3Market Value 4Market Value 5Sources of Income (other than wages)Pension or Other Sources of Income (other than wages)Source2 Source3 Source4 Source5 SourceAccount HolderAccount Holder 2Account Holder 3Account Holder 4Account Holder 5Monthly AmountMonthly Amount 2Monthly Amount 3Monthly Amount 4Monthly Amount 5Start DateStart Date 2Start Date 3Start Date 4Start Date 5PreviousNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit