Risk Tolerance Questionnaire Form – Rosenberg Wealth Management

Rosenberg

Wealth Management

Protection, Honesty, Legacy.

Financial & Suitability
Onboarding Questionnaire

Section 1 of 11 9%

SECTION 1: CONTACT PROFILES

Partner 1

Partner 1 Full Legal Name:

Birth Date (MM/DD/YYYY):

Primary Phone:

Cell Phone:

Marital Status:

Email Address:

Social Security #:

Partner 2

Partner 2 Full Legal Name:

Birth Date (MM/DD/YYYY):

Primary Phone:

Cell Phone:

Marital Status:

Email Address:

Social Security #:

Residential Address

Residential Street Address:

Apt / Suite:

City, State, and Zip Code:

SECTION 2: FAMILY & BENEFICIARY INFORMATION

FULL LEGAL NAME	RELATIONSHIP	BIRTH DATE	BENEFICIARY %

SECTION 3: PRIMARY FINANCIAL GOALS & TARGETS

SELECT	RETIREMENT CORE TARGET	TARGET YEAR	BRIEF OBJECTIVE DESCRIPTION
	Retirement Allocations
	Vacations & Travel Outlays
	College / Education Funding
	Second Home Acquisition
	Capital Vehicle Purchases

SECTION 4: INCOME STREAMS & EXPENSES

A. EMPLOYMENT & ACTIVE INCOME

ACTIVE EMPLOYMENT PARAMETER	PARTNER 1	PARTNER 2
Employer Organization / Firm Name
Gross Monthly Salary Base
Projected Annual Salary Increase Percentage
Projected Retirement Date / Active Status	Already Retired	Already Retired

B. SOCIAL SECURITY INCOME STREAMS

OWNER	CLAIMING STRATEGY	START AGE	LIFE OR END AGE	GROSS MONTHLY BENEFIT
Partner 1			Life or
Partner 2			Life or

C. DEFINED BENEFIT PENSION INCOME

OWNER	DESCRIPTION / CARRIER	START AGE	LIFE OR END AGE	GROSS MONTHLY BENEFIT
			Life or
			Life or

D. CONSOLIDATED HOUSEHOLD CASH FLOW

1. Total Combined Monthly Household Income (Salary, Pension, Social Security, Investment Cash):

2. Total Combined Monthly Household Debts & Routine Expenses (Mortgage, Groceries, Insurance):

SECTION 5: HOUSEHOLD ASSETS & LIABILITIES

Important Step: Do not include values for your primary residential home, personal vehicles, or common possessions below.

HOUSEHOLD LIQUID ASSETS

HOUSEHOLD LIQUID ASSETS	AMOUNT
1. Stocks/Bonds/Mutual Funds/Brokerage
2. Checking / Savings / Cash CDs
3. Pension / 401(k) (Owners Over 59½)
4. Life Insurance Matured Cash Value
5. Settled Death Claim Proceeds
6. Annuities Outside Surrender Period
7. Total Liquid Household Assets

HOUSEHOLD NON-LIQUID ASSETS

HOUSEHOLD NON-LIQUID ASSETS	AMOUNT
8. Annuities Inside Surrender Period
9. Pension / 401(k) (Owners Under 59½)
10. Private Limited Partnerships
11. Total Non-Liquid Assets

HOUSEHOLD LIABILITIES (DEBT)

HOUSEHOLD LIABILITIES (DEBT)	AMOUNT
12. Second Mortgage / HELOC Balance
13. Credit Card Outstanding Balances
14. Active Student Loan Debt

SECTION 6: EXPERIENCE & TAX PROFILE

3. HISTORICAL TRACKING EXPERIENCE WITH FINANCIAL INSTRUMENTS

ASSET CLASSIFICATION PROFILE	NONE	1-4 YEARS	5-9 YEARS	10+ YEARS
Stocks / Mutual Funds / Active Brokerage Accounts
Certificates of Deposit (CD Asset Reserves)
Life Insurance Contracts or Annuities (Fixed/Variable)
Qualified Workplace Accounts (Pension / 401k / 403b)

SECTION 8: STRATEGIC FINANCIAL OBJECTIVES & FUNDING SOURCES

1. Primary Structural Objective for the assets being reviewed (Select all that apply):

Guaranteed Preservation of Capital Principal Growth & Account Accumulation

Efficient Asset Transfer to Beneficiaries Income Tax Deferral Planning

2. Intended Capital Funding Sources (Select all choices that match this execution):

Fiduciary Compliance Notice: Reverse Mortgages or Home Equity Loan drawing actions are strictly prohibited sources of capital.

3. Anticipated Withdrawal Actions & Distribution Horizon Matrix:

DISTRIBUTION FRAMEWORK OPTION	IMMEDIATE	1-5 YEARS	6-10 YRS	11+ YRS	UNKNOWN
a. Penalty-Free Partial Withdrawals
b. Contract Annuitization Structured Payouts
c. Required Minimum Distributions (RMD Setup)
d. Guaranteed Living Withdrawal Benefit (GLWB)
e. Full Lump Sum Account Settlement

4. Historic Replacements & Transfers Verification

Excluding today's planning action, have you exchanged, rolled over, or altered any life insurance policy or annuity vehicle within the past 5 calendar years?

Yes No

SECTION 9: LONG-TERM CARE ASSET PROTECTION DETAILS

SECTION 10: PLEASE LIST YOUR THREE MOST IMPORTANT GOALS TO ACCOMPLISH

Goal 1

Goal 2

Goal 3

SECTION 11: COMPLIANCE ATTESTATIONS & SIGNATURE EXECUTION

By executing this document below, I hereby attest that all data and valuations supplied within this financial questionnaire have been provided directly by me, and to the best of my knowledge, represent an accurate snapshot of my physical financial position. I understand that these personal tracking metrics will be integrated into retirement software to establish my customized retirement cash flow analysis.

I explicitly recognize and understand that insurance professionals operating with fixed-only licensure are legally restricted from recommending the sale, liquidation, or restructuring of active securities accounts to clear fund balances for insurance implementations. Separate securities registrations are mandatory to provide advice or execute liquidations inside investment product frameworks. All information gathered here will be used solely to design a comprehensive financial strategy for my retirement years. The wealth professional leading this discovery process offers retirement overviews and does not render formal legal or tax opinions.

Partner 1 / Primary Applicant Signature

Printed Name:

Date Signed:

Partner 2 / Joint Applicant Signature

Printed Name:

Date Signed:

Managing Fiduciary Advisor Signature

Daniel Rosenberg | Rosenberg Wealth Management

Review Date:

Review Questionnaire

Please review the information entered above before generating the completed questionnaire PDF.

OWNER	INSURANCE CARRIER	POLICY TYPE	DAILY BENEFIT	INFLATION TYPE	MO. PREMIUM
		Cash Reimb.		Simple Comp.
		Cash Reimb.		Simple Comp.