FINANCIAL MANAGEMENT QUESTIONNAIRE

This information will be used to prepare an individual report assessing your current financial needs. Your responses will not be sold or shared with any unaffiliated parties.

STEP #1 Please complete the following forms, including as much information as possible. Please
complete only the items that apply to your situation.

STEP #2 Using the following check-list, include copies of all documents:

 Business documents (buy/sell agreements, approximate business value)
 Children’s assets or UGMAs (most recent statements)
 Copies of Current Driver’s license(s)
 Copy of Monthly Budget
 Employee benefits booklets
 Financial statement (most recent statements)
 Insurance policies (life, health, disability, long-term care, etc.)
 K-1s for limited partnership interests
 Loan Information (auto, credit card and lines of credit – most recent statements)
 Mortgage information for home, property & business
 Recent Pay stub
 Retirement Plans (pension, IRAs, KEOGH, 401(k))
 Statements for invested money* (most recent statements of: Stocks, bonds, mutual funds, limited partnership
*Please include the cost basis for each investment – the cost basis is necessary to determine the value of your
investment.

 Tax returns - last two years, Federal and State (personal, corporation, partnership)
 Trust agreements
 Wills
 Social Security Statement (You can create a profile and print a copy at https://www.ssa.gov/myaccount/)

STEP #3
 Return to: Mowatt Financial Inc.
383 Inverness Parkway, Suite 400
Englewood, CO 80112

 If you have any questions, please do not hesitate to contact our office at 303-843-9500.

303-503-6061 • dave@mowattfinancial.com • 12451 Twineagles Blvd. • Naples, FL 34120

Registered Principal offering securities and advisory services through Independent Financial Group, LLC (IFG), A Registered
Broker/Dealer, Member: FINRA/SIPC.

Mowatt Financial and IFG are unaffiliated entities.

 No Plan Will Be Completed Without the Information Listed On This Page *

FIRST NAME M.I. LAST NAME NICKNAME

CLIENT
HOME PHONE ( ) - HOME FAX ( ) - CELL PHONE ( ) - M/F
ADDRESS CITY ST ZIP CODE
DATE OF BIRTH / MARITAL STATUS
DRIVER’S LICENSE – ATTACH COPY EMAIL CITIZENSHIP
PREFERRED MAILING ADDRESS:  HOME  WORK  P.O.BOX
EMPLOYER/OCCUPATION /
WORK ADDRESS CITY ST ZIP CODE
WORK PHONE NUMBER ( ) - WORK FAX NUMBER ( ) -
MOTHER’S MAIDEN NAME

FIRST NAME M.I. LAST NAME NICKNAME

SPOUSE
HOME PHONE ( ) - HOME FAX ( ) - CELL PHONE ( ) - M/F
ADDRESS CITY ST ZIP CODE
DATE OF BIRTH / MARITAL STATUS
DRIVER’S LICENSE – ATTACH COPY EMAIL CITIZENSHIP
PREFERRED MAILING ADDRESS:  HOME  WORK  P.O.BOX
EMPLOYER/OCCUPATION /
WORK ADDRESS CITY ST ZIP CODE
WORK PHONE NUMBER ( ) - WORK FAX NUMBER ( ) -
MOTHER’S MAIDEN NAME

DEPENDANTS FIRST NAME M.I. LAST NAME M/F

Date of Birth / /
CURRENT ASSETS
FIRST NAME M.I. LAST NAME M/F
Date of Birth / /
CURRENT ASSETS

PLAN FILING STATUS TAX BRACKET MONTHLY RETIREMENT NEEDS $

INFORMATION CLIENT’S DESIRED RETIREMENT AGE SPOUSE DESIRED RETIREMENT AGE

DO YOU EXPECT TO GET THE MAXIMUM SOCIAL SECURITY? YES/NO
ARE YOU A DEFENDANT IN ANY LAWSUIT? YES/NO
DO YOU HAVE ANY PAST BANKRUPTCY? YES/NO

IMPORTANT NAME OF ACCOUNTANT FIRM

WORK ADDRESS CITY ST ZIP CODE
INDIVIDUALS WORK PHONE NUMBER ( ) - WORK FAX NUMBER ( ) -
Accountant, NAME OF ATTORNEY FIRM
Attorney,
Executor of Wills, WORK ADDRESS CITY ST ZIP CODE
Children’s Guardian WORK PHONE NUMBER ( ) - WORK FAX NUMBER ( ) -

NAME OF EXECUTOR OF WILLS FIRM

WORK ADDRESS CITY ST ZIP CODE
WORK PHONE NUMBER ( ) - WORK FAX NUMBER ( ) -

NAME OF CHILDREN’S GUARDIAN _________

WORK ADDRESS CITY ST ZIP CODE
 GOALS & OBJECTIVE: (CHOOSE ONLY ONE): INCOME GROWTH TOTAL RETURN

OBJECTIVES INVESTMENT EXPERIENCE (YEARS): TOLERANCE: (CHOOSE ONLY ONE)

EQUITIES DIRECT PARTICIPATION PROGRAMS CONSERVATIVE
FIXED INCOME REITS MODERATE
OPTIONS ANNUITIES AGGRESSIVE
MUTUAL FUNDS REAL ESTATE

INCOME
SOURCE SALARY/BONUS/DIVIDEND AMOUNT
INFORMATION

BANK / CASH BANK ACCOUNT ID

CURRENT BALANCE DATE OPENED
ASSETS
TYPE OF ACCOUNT  CHECK  SAVINGS  MONEY MARKET  CD  OTHER
Savings, OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER
Checking,
Certificates ACCUMULATE FOR RETIREMENT FUNDING? YES/NO
Of Deposit,
Money Markets
BANK ACCOUNT ID
CURRENT BALANCE DATE OPENED
TYPE OF ACCOUNT  CHECK  SAVINGS  MONEY MARKET  CD  OTHER
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER
ACCUMULATE FOR RETIREMENT FUNDING? YES/NO

BANK ACCOUNT ID
CURRENT BALANCE DATE OPENED
TYPE OF ACCOUNT  CHECK  SAVINGS  MONEY MARKET  CD  OTHER
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER
ACCUMULATE FOR RETIREMENT FUNDING? YES/NO

BANK ACCOUNT ID
CURRENT BALANCE DATE OPENED
TYPE OF ACCOUNT  CHECK  SAVINGS  MONEY MARKET  CD  OTHER
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER
ACCUMULATE FOR RETIREMENT FUNDING? YES/NO

SECURITIES DESCRIPTION/ FIRM ACCOUNT TYPE ___________________________________________

ACCOUNT NUMBER ___________________________________________________________________
INFORMATION
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER  STATEMENT ATTACHED
Stocks,
Mutual Funds,
Bonds DESCRIPTION/ FIRM ACCOUNT TYPE ___________________________________________
ACCOUNT NUMBER ___________________________________________________________________
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER  STATEMENT ATTACHED

DESCRIPTION/ FIRM ACCOUNT TYPE ___________________________________________

ACCOUNT NUMBER ___________________________________________________________________
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER  STATEMENT ATTACHED

DESCRIPTION/ FIRM ACCOUNT TYPE ___________________________________________

ACCOUNT NUMBER ___________________________________________________________________
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER  STATEMENT ATTACHED
 REAL ADDRESS
ESTATE TYPE  RESIDENCE  VACATION  INVESTMENT  OTHER
CURRENT VALUE INTEREST RATE PAYMENT AMOUNT
MORTGAGE BALANCE PURCHASE COST PURCHASE DATE
ORIGINAL LOAN PERIOD/ LOAN TYPE_________________

ADDRESS
TYPE  RESIDENCE  VACATION  INVESTMENT  OTHER
CURRENT VALUE INTEREST RATE PAYMENT AMOUNT
MORTGAGE BALANCE PURCHASE COST PURCHASE DATE
ORIGINAL LOAN PERIOD/ LOAN TYPE_________________

ADDRESS
TYPE  RESIDENCE  VACATION  INVESTMENT  OTHER
CURRENT VALUE INTEREST RATE PAYMENT AMOUNT
MORTGAGE BALANCE PURCHASE COST PURCHASE DATE

LIMITED DESCRIPTION ACCOUNT ID

PARTNERSHIP/ OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER
ACCUMULATE FOR RETIREMENT FUNDING? YES/NO
BUSINESS
UNITS PURCHASED PURCHASE DATE CURRENT VALUE COST/UNIT
INTERESTS

DESCRIPTION ACCOUNT ID
OWNERSHIP  CLIENT  SPOUSE  JOINT  CHILD  OTHER
ACCUMULATE FOR RETIREMENT FUNDING? YES/NO
UNITS PURCHASED PURCHASE DATE CURRENT VALUE COST/UNIT

LIFE IN THE EVENT OF YOUR DEATH, WHAT IS THE TOTAL MONTHLY INCOME NEEDED FOR YOUR FAMILY?
IN THE EVENT OF YOUR SPOUSE’S DEATH, WHAT IS THE TOTAL MONTHLY INCOME NEEDED FOR YOUR FAMILY?
INSURANCE

POLICY NUMBER CARRIER POLICY TYPE

INSURED BENEFICIARY POLICY DATE
CASH VALUE _______FACE VALUE __PREMIUM AMOUNT _________PAYMENT INTERVAL
LOAN AMOUNT

POLICY NUMBER CARRIER POLICY TYPE

INSURED BENEFICIARY POLICY DATE
CASH VALUE _______FACE VALUE __PREMIUM AMOUNT _________PAYMENT INTERVAL
LOAN AMOUNT

POLICY NUMBER CARRIER POLICY TYPE

INSURED BENEFICIARY POLICY DATE
CASH VALUE _______FACE VALUE __PREMIUM AMOUNT _________PAYMENT INTERVAL
LOAN AMOUNT

POLICY NUMBER CARRIER POLICY TYPE

INSURED BENEFICIARY POLICY DATE
CASH VALUE _______FACE VALUE __PREMIUM AMOUNT _________PAYMENT INTERVAL
LOAN AMOUNT

IN THE EVENT OF
*PLEASE PROVIDE ATOTAL
COPY DISABILITY
OF ALL, WHATCURRENT
WOULD YOUR MONTHLY INCOME NEEDS
POLICIES, ALONGBE? WITH A CURRENT STATEMENT
________
 DISABILITY POLICY NUMBER CARRIER POLICY TYPE

INSURANCE INSURED OWNER PAYOR

WAITING PERIOD EFFECTIVE DATE PREMIUM AMOUNT MONTHLY BENEFIT

POLICY NUMBER CARRIER POLICY TYPE

INSURED OWNER PAYOR
WAITING PERIOD EFFECTIVE DATE PREMIUM AMOUNT MONTHLY BENEFIT

HEALTH
POLICY NUMBER CARRIER POLICY TYPE
INSURANCE COVERAGE $ PERCENTAGE PREMIUM AMOUNT
DEPENDENT COVERAGE DENTAL COVERAGE VISION COVERAGE

POLICY NUMBER CARRIER POLICY TYPE

COVERAGE $ PERCENTAGE PREMIUM AMOUNT
DEPENDANT COVERAGE DENTAL COVERAGE VISION COVERAGE

LONG TERM POLICY NUMBER CARRIER POLICY TYPE  GROUP  INDIVIDUAL  OTHER
CARE EFFECTIVE DATE PREMIUM DATE PREMIUM AMOUNT
DEPENDANT AMOUNT PER PERSON LIMIT
INSURANCE

POLICY NUMBER CARRIER POLICY TYPE  GROUP  INDIVIDUAL  OTHER

EFFECTIVE DATE PREMIUM DATE PREMIUM AMOUNT
DEPENDANT AMOUNT PER PERSON LIMIT

ALL

ADDITIONAL

INSURANCE

INFORMAITON

*PLEASE PROVIDE A COPY OF ALL CURRENT POLICIES, ALONG WITH A CURRENT STATEMENT
PENSION &
DESCRIPTION TYPE  401K  PSP  KEOGH  IRA  SEP  PENSION  MILITARY OTHER
RETIREMENT
OWNERSHIP CLIENT SPOUSE OTHER BASE COST PURCHASE DATE
PLANS VALUE DATE/AGE AVAILABLE HOW ARE BENEFITS RECEIVED?  MONTHLY  ANNUALLY  LUMP SUM
OTHER INFORMATION

DESCRIPTION TYPE  401K  PSP  KEOGH  IRA  SEP  PENSION  MILITARY OTHER
OWNERSHIP CLIENT SPOUSE OTHER BASE COST PURCHASE DATE
VALUE DATE/AGE AVAILABLE HOW ARE BENEFITS RECEIVED?  MONTHLY  ANNUALLY  LUMP SUM
OTHER INFORMATION

DESCRIPTION TYPE  401K  PSP  KEOGH  IRA  SEP  PENSION  MILITARY OTHER
OWNERSHIP CLIENT SPOUSE OTHER BASE COST PURCHASE DATE
VALUE DATE/AGE AVAILABLE HOW ARE BENEFITS RECEIVED?  MONTHLY  ANNUALLY  LUMP SUM
OTHER INFORMATION

BUSINESS / NAME ON NOTE:

MISC. NOTES DATE NOTE WAS ISSUED: DATE NOTE DUE:

PAYABLE TO NOTE PAYMENT:  PER MONTH  PER QUARTER  PER YEAR
CLIENT
NOTE INTEREST: LENGTH OF TERM: PRINCIPLE BALANCE:

VEHICLES MAKE_______________________________ MODEL_________________________________YEAR______________________

PURCHASE DATE ____________________ PURCHASE COST_______________MONTHLY PAYMENT AMOUNT___________________
TOTAL BALANCE OWED ON VEHICLE______________________CURRENT VALUE_________________________________________

MAKE_______________________________ MODEL_________________________________YEAR______________________
PURCHASE DATE ____________________ PURCHASE COST_______________MONTHLY PAYMENT AMOUNT___________________
TOTAL BALANCE OWED ON VEHICLE______________________CURRENT VALUE_________________________________________

MAKE_______________________________ MODEL_________________________________YEAR______________________
PURCHASE DATE ____________________ PURCHASE COST_______________MONTHLY PAYMENT AMOUNT___________________
TOTAL BALANCE OWED ON VEHICLE______________________CURRENT VALUE_________________________________________

OTHER
INFORMATION *Please list any credit cards, lines of credit, and 401(k) loans and the current balances below:

______________________________________________________________________BALANCE ______________________

______________________________________________________________________BALANCE ______________________

______________________________________________________________________BALANCE ______________________

______________________________________________________________________BALANCE ______________________

______________________________________________________________________BALANCE ______________________
 Monthly Budget
Worksheet
Complete worksheet using your last month's activity
Income
Spouse Income
CLIENT NAME: Additional Income

Household monthly Income total:

HOUSING Monthly Amount ENTERTAINMENT Monthly Amount

Mortgage or rent Video/DVD
Phone CDs
Electricity Movies
Gas Concerts
Water and sewer Sporting events
Cable Live theater
Waste removal Other

Maintenance or repairs Other

Supplies Other
Other Subtotal:
Subtotal:
LOANS Monthly Amount
TRANSPORTATION Monthly Amount Personal
Vehicle payment Student
Bus/taxi fare Credit card
Insurance Credit card
Licensing Credit card
Fuel Other
Maintenance Subtotal:
Other
Subtotal: TAXES Monthly Amount
Federal
INSURANCE Monthly Amount State
Home Local
Health Other
Life Subtotal:
Subtotal:
SAVINGS OR INVESTMENTS Monthly Amount
FOOD Monthly Amount Retirement account
Groceries Investment account
Dining out Other
Other Subtotal:
Subtotal:
PETS Monthly Amount GIFTS AND DONATIONS Monthly Amount

Food Charity 1
Medical Charity 2
Grooming Charity 3
Toys Subtotal:
Other
Subtotal: LEGAL Monthly Amount

Attorney
PERSONAL CARE Monthly Amount Alimony
Medical Payments on lien or judgment
Hair/nails Other
Clothing Subtotal:
Dry cleaning
Health club OTHER (MISC) Monthly Amount

Organization dues or
fees
Other

Subtotal:

Subtotal:

TOTAL MONTHLY EXPENSES:

TOTAL BALANCE:
(income minus expenses)