Home Phone:
You:
Name:
Birthday:
Social Security#:
Spouse/ Partner:
Name:
Birthday:
Social Security#
Home Address:
City/State/Zip:
Email Address:
You:        
Employer:
Phone:
Year Employed:
Salary:
Spouse/ Partner:        
Employer:
Phone:
Year Employed:
Salary:
Tax Bracket: % 
Other Sources of Income:
Dependents:
If button is left unchecked it will automatically default to no when form is submitted.
Name: DOB In College In Nursing Care
Yes   No Yes   No
Yes   No Yes   No
Yes   No Yes   No
Yes   No Yes   No

Do you qualify for Social Security?
You: Yes No
Spouse/ Partner: Yes No

At what age would you like to retire?: You: Spouse/Partner:
Number of years in a Pension Plan?: You: Spouse/Partner:
Expected Annual Pension Income?: You: Spouse/Partner:

Do you have a will or trust?
You: Yes No
Spouse/Partner: Yes No


What are your financial goals?
1.
2.
3.

 
Most concerned about: (Choose 3)      
Reducing taxes:    
Accumulating retirement money:    
Protection from inflation:    
Maximum investment growth:    
Keeping funds liquid:    
Current income from assets:    
Better investment diversification:    
Other:    

Risk Tolerance:
Conservative
Aggressive    
 
 1    2    3    4    5    6    7    8    9    10    

  
  

Please list total of debts in each category:
Home mortgage: $     
Credit Cards: $     
Auto Loans: $     
Personal Loans: $     
School Loans: $     
Other: $     
 
Do you have any life, disability or long term care insurance policies?
(Please List)
Company: Whose Life: Death Benefits Cash Value Year Purchased


Investment Asset Allocation....................Click on the Question mark for definitions.
         
Cash:            
Investment: Balance:
Total $
 This number will be calculated for you.
% Of Assets
This number will be calculated for you.

Income:    
Investment: Balance:
Total $
 This number will be calculated for you.
% Of Assets
This number will be calculated for you.

Equity:    
Investment: Balance:
Total $
 This number will be calculated for you.
% Of Assets
This number will be calculated for you.

Real Estate:    
Investment: Balance:
Total $
 This number will be calculated for you.
% Of Assets
This number will be calculated for you.


 
  
Copyright © 2006 Dearborn & Creggs Investments. All Rights Reserved. 77 Sugar Creek Center Blvd. Suite 590 Sugar Land, TX. 77478 (281) 277- 6400 Advisory Services and Securities offered through Lincoln Investment Planning, Inc. Registered Investment Advisor, Broker Dealer, Member NASD/SIPC. Lincoln Investment Planning, Inc. and Dearborn & Creggs are independently owned and each is responsible for its own business.