Client Questionnaire

Home
Resources
Preliminary Data Questionnaire (PDQ)

Preliminary Data Questionnaire (PDQ)

Please fill out the form below and press Submit.
Note, if you navigate away from the page before completion, your data will not be saved.

If Preferred, Download a Fillable PDF of the PDQ here.

Upload all Secure Documents and Completed PDQs Here.

Fill Form
Upload PDF

PDF

Once you click submit, you will not be able to change any of your responses.

Thank you for submitting your Preliminary Data Questionnaire (PDQ).

It has been securely submitted to our Stavis Wealth team, and we will be in touch shortly!

ClientClient's NameClient's Date of BirthIs Client a US Citizen

Yes

Client's E-mailClient's Cell PhoneClient's Home Phone

SpouseSpouse's NameSpouse's Date of BirthIs Spouse a US Citizen?

Yes

Spouse's Cell Phone

ChildChild's NameChild's Date of BirthChild's Marital Status

Single

Married

Separated

Divorced

Is Child a US Citizen?

Yes

Child's SpouseChild's Spouse's NameChild's Spouse's Date of BirthChild's Spouse's Marital Status

Single

Married

Separated

Divorced

Is Child's Spouse a US Citizen?

Yes

ChildChild's NameChild's Date of BirthChild's Marital Status

Single

Married

Separated

Divorced

Is Child a US Citizen?

Yes

Child's SpouseChild's Spouse's NameChild's Spouse's Date of BirthChild's Spouse's Marital Status

Single

Married

Separated

Divorced

Is Child's Spouse a US Citizen?

Yes

ChildChild's NameChild's Date of BirthChild's Marital Status

Single

Married

Separated

Divorced

Is Child a US Citizen?

Yes

Child's SpouseChild's Spouse's NameChild's Spouse's Date of BirthChild's Spouse's Marital Status

Single

Married

Separated

Divorced

Is Child's Spouse a US Citizen?

Yes

ChildChild's NameChild's Date of BirthChild's Marital Status

Single

Married

Separated

Divorced

Is Child a US Citizen?

Yes

Child's SpouseChild's Spouse's NameChild's Spouse's Date of BirthChild's Spouse's Marital Status

Single

Married

Separated

Divorced

Is Child's Spouse a US Citizen?

Yes

GrandchildGrandchild's NameGrandchild's Date of BirthGrandchild's Marital Status

Single

Married

Separated

Divorced

Is Grandchild a US Citizen?

Yes

GrandchildGrandchild's NameGrandchild's Date of BirthGrandchild's Marital Status

Single

Married

Separated

Divorced

Is Grandchild a US Citizen?

Yes

GrandchildGrandchild's NameGrandchild's Date of BirthGrandchild's Marital Status

Single

Married

Separated

Divorced

Is Grandchild a US Citizen?

Yes

GrandchildGrandchild's NameGrandchild's Date of BirthGrandchild's Marital Status

Single

Married

Separated

Divorced

Is Grandchild a US Citizen?

Yes

Great GrandchildGreat Grandchild's NameGreat Grandchild's Date of BirthGreat Grandchild's Marital Status

Single

Married

Separated

Divorced

Is Great Grandchild a US Citizen?

Yes

Great GrandchildGreat Grandchild's NameGreat Grandchild's Date of BirthGreat Grandchild's Marital Status

Single

Married

Separated

Divorced

Is Great Grandchild a US Citizen?

Yes

Great GrandchildGreat Grandchild's NameGreat Grandchild's Date of BirthGreat Grandchild's Marital Status

Single

Married

Separated

Divorced

Is Great Grandchild a US Citizen?

Yes

Great GrandchildGreat Grandchild's NameGreat Grandchild's Date of BirthGreat Grandchild's Marital Status

Single

Married

Separated

Divorced

Is Great Grandchild a US Citizen?

Yes

PropertyReal Estate/PersonalCurrent Value ($)Tax Basis ($)Owner

InvestmentType/InstitutionCurrent Value ($)Tax Basis ($)Owner

RetirementType/InstitutionCurrent Value ($)OwnerBeneficiaryEmployee Contribution ($)Employer Contribution ($)

Business AssetBusiness NameBase Value ($)Tax Basis ($)OwnerBusiness Type

Sole Proprietor

C Corp

S Corp

Limited Liability Corp

Family Limited Partnership

Business AssetBusiness NameBase Value ($)Tax Basis ($)OwnerBusiness Type

Sole Proprietor

C Corp

S Corp

Limited Liability Corp

Family Limited Partnership

Business AssetBusiness NameBase Value ($)Tax Basis ($)OwnerBusiness Type

Sole Proprietor

C Corp

S Corp

Limited Liability Corp

Family Limited Partnership

Business AssetBusiness NameBase Value ($)Tax Basis ($)OwnerBusiness Type

Sole Proprietor

C Corp

S Corp

Limited Liability Corp

Family Limited Partnership

InsurancePolicy NumberInsurance CarrierPurchase DatePolicy Type

Term

Variable Life

Universal Life

Private Placement Life

Disability

Long Term Care

Person InsuredOwnerBenefit Amount ($)Beneficiary (if applicable)Cash Value ($) (if applicable)Annual Premium ($)Premium / Benefit TermPremium PayerDoes your Insurance continue to fill a need?Do you work closely with a life insurance agent?

InsurancePolicy NumberInsurance CarrierPurchase DatePolicy Type

Term

Variable Life

Universal Life

Private Placement Life

Disability

Long Term Care

InsurancePolicy NumberInsurance CarrierPurchase DatePolicy Type

Term

Variable Life

Universal Life

Private Placement Life

Disability

Long Term Care

InsurancePolicy NumberInsurance CarrierPurchase DatePolicy Type

Term

Variable Life

Universal Life

Private Placement Life

Disability

Long Term Care

LiabilityMortgage/LoansMortgage Origination DateInstitution DateCurrent Balance ($)As of DateInterest RateLoan Term

SalarySocial Security NumberAnnual Amount ($)OwnerStartsEnds

Spouse's SalarySpouse's Social Security NumberAnnual Amount ($)OwnerStartsEnds

ExpensesCurrent ($)Semi-Retirement ($)Retirement ($)Advanced Years ($)

Desired Income upon RetirementClient's Retirement ($)Spouse's Retirement ($)

Current Estate PlansClient

Simple Will

Revocable Life Trust

Irrevocable Life Insurance Trust

Family Limited Partnership

Business Succession Documents

Other

Current Estate Plan Notes

Spouse's Estate PlansSpouse

Simple Will

Revocable Life Trust

Irrevocable Life Insurance Trust

Family Limited Partnership

Business Succession Documents

Other

Current Estate Plan Notes

Financial Advisor / Investment Manager QuestionsDo you have a financial advisor / investment manager?

Yes

Is your financial advisor / investment manager a key decision maker for you?

Yes

Would you like us to recommend someone?

Yes

Attorney QuestionsDo you have an attorney?

Yes

Is your attorney a key decision maker for you?

Yes

Would you like us to recommend someone?

Yes

CPA QuestionsDo you have a CPA?

Yes

Is your CPA a key decision maker for you?

Yes

Would you like us to recommend someone?

Yes

Personal QuestionsDo you feel you have achieved financial security through retirement?

Yes

Do you have any potential inheritances?

Yes

How would you like to pass your estate?Do you plan to leave any portion of your estate to charity?

Yes

Do you need to make any special financial provisions for any member of your family?

Yes

If yes, who?What are your plans to deal with Estate Taxes?What is your largest obstacle in achieving your goals?Are you willing to invest effort/money, if plan serves to reduce/eliminate tax?

Yes

Financial Risk Tolerance

Conservative

Moderate

Aggressive

When were these last reviewed?

Life Insurance ProgramProperty and Casual

Once you click submit, you will not be able to change any of your responses.

Thank you for submitting your Preliminary Data Questionnaire (PDQ).

It has been securely submitted to our Stavis Wealth team, and we will be in touch shortly!