ConfidentialFinancialQuestionnaire

JACQUES FINANCIAL, LLC15430 AVERY ROAD www.JacquesFinancial.com ph (301) 738-1303ROCKVILLE, MD 20855 e-mail: Invest@JacquesFinancial.com fax (301) 738-1305

IMPORTANT INFORMATION about procedures for opening a new account: To help the government fight the funding of terrorism and money laundering activities, Federal law requires allfinancial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, you are required to provide your name, residential address,date of birth, and identification number. We may require other information that will allow us to identify you.

Personal data

Occupational dataspouse self-employed?Are either you or your

CitizenshipSocial Security NumberDate of BirthMarital StatusName

Client

Spouse

Child

Child

Child

Child

Child

Child

Driver's License State, #

SpouseClient

EMailLegal Residence

ClientAddressStreet

ZIPCity, State &

SpouseTelephoneHome

‘ Corporation ‘ Partnership ‘ Sole Proprietorof business:If yes, type

SpouseClient

Your Title

Employer

AddressStreetEmployer

ZIPCity, State &

Telephone

ServiceYears of

Occupational data

short-term disability?Does your employer provide

_____________Income/percent of salary:

ContributionsPlan Allowing Voluntary

_____________Income/percent of salary:

MedicalComprehensive Major

much do you contribute?Are any of these plans contributors? If yes, how

Year drafted:executed wills? Do you have valid

deposit box?Do you have a safe

name:attorney? If yes,Do you have an

name:accountant? If yes,Do you have an

Smokers?medical problems? member have anyDo you or any family

Work-Related Benefits

Does your employer provide life insurance? ____Does your company have (check as many as appropriate)

Coverage:SpouseClient

Amount of Contribution:Pension Plan

401k Plan

Profit Sharing

of time:Length

Thrift/Savings Plan

Long-term disability?Stock Option Plan

of time:Length

Deferred Compensation

Dental Benefits

$ _________________________

Income Sources

JointSpouseClient

Base Salary

Bonuses

Fees and Commissions

Rental Income

Royalties

Trust Income

Business Income

Income Sources

Asset Inventory1. Savings

Maturity Date% ReturnAmountTitled Owner

Passbook Savings

Passbook Savings

Credit Union Account

Credit Union Account

Checking Account

Checking Account

Certificate of deposit

Certificate of deposit

Certificate of deposit

Certificate of deposit

Money Market Fund

Money Market Fund

Savings bonds

Treasury bills

IRA

IRA

IRA

IRA

Custodial accounts

Custodial accounts

Annuities

Annuities

Other

Other

Asset Inventory2. Marketable Securities (Stocks, bonds, mutual funds)

Annual IncomeCMVCost BasisDate Bought# of SharesItemTitled Owner

3. Real Estate

CurrentImprovementsTitlePriceYearMarket ValueCapital ExpendituresBought

ResidencePrimary

HomeOther

HomeOther

LandUndeveloped

LandUndeveloped

Other

Debt

loans, car loans, credit cards, store charges, checking credit line, etc.)2. Loans (includes personal loans, college loans, home improvement loans, passbook

1. Mortgages

Monthly PrincipalApproximateInterest and TaxesBalanceInterest RateAmountTermLoan Date

ResidencePrimary

InsuredPay-off DateBalanceMonthlyType ofYes/NoRemainingPaymentLoan

Protection Analysis

FeatureHome Health Care

1. Life Insurance

Policy #4Policy #3Policy #2Policy #1

Name of insured

Insurance Company

Premium amount

Dividends

Dividend Use

Policy loans

Type of policy

Amount of coverage

2. Disability Insurance

Policy #4Policy #3Policy #2Policy #1

Name of insured

Insurance Company

Amount of coverage

Individual or Group

Premium/Mode

Waiting period

Benefit period

3. Long-Term Care Insurance

Policy #4Policy #3Policy #2Policy #1

Name of insured

Insurance Company

Premium amount

Waiting period

Benefit period

Daily benefit

Asset Inventory

primary source of cash assets?savings, etc.) If no, what was theand by what method (i.e. payrollsaving? If yes, in what amountIs there a regular pattern of

current rate of saving:Attitude toward

vehicles:selecting savingsUsual method of

repositioned. Explain.client feels cannot bespecific objectives and those theIdentify accounts earmarked for

Education

What is a reasonable after-tax return?Attitude toward current performance:

Annual financial obligation for education

Type ofPlannedExistingAnnual Expense in Today's DollarsAgeChild

AccountAnnual SavingsSavingsGraduateUndergraduate

Spouse to answer.read the questions aloud. Allow both Client andintroductory comment in quotation marks andbelow with the appropriate information. Read theNote: be prepared to fill in the items lined outFamily Needs

were to die today:family's financial situation if youGive a brief description of your

your present home?or opportunity to continue living in(mention names) the financial optionIs it important to give your family

self-sufficient?Children) until the children areincome to (name Spouse andIs it important to provide a monthly

is paid for.a monthly basis; assume your housedollars--would you want provided onWhat amount--in today's

complete their education?children have the opportunity toIs it important to you that your

provide each child for this?What amount would you want to

be?What will the source of these funds

Risk Tolerance

your financial objectives?risk is reasonable to take to meetinvolve some risk, what amount ofKeeping in mind that all investments

5

Speculative (high risk)

"The next questions are a little unusual because we need to assume you have passed away

SpouseClient

Are you happy with this situation?

What do you feel is a realistic future inflation rate?

101

Conservative (low risk)

and objectivesFinancial goals

has not been discussed?you (from a financial standpoint) that1. Is there anything of importance to

plans?might cause a change in your futureother unusual circumstances thatfinances, personal situation or anyelse we should know about your2. Do you feel that there is anything

make decisions on your own?seek or do you (and your spouse)there someone whose advice youinvestment or savings decisions, is3. When it comes to making

planning to do for you?4. What do you expect financial

Notes