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Financial Fitness Survey (Retirement)
Your responses to the following statements will help you to identify the areas where you could benefit from when working with a financial planner.
Please indicate your response to each statement where:
1 = Unsure or do not know 2 = No (not true) 3= Sometimes 4= Yes (that’s me)
Leave blank if not applicable.
Name *
Your answer
1. Quality of life – I feel comfortable…
with where I currently live
Unsure/No
Yes
with the level of my savings
Unsure/No
Yes
with the level of my income
Unsure/No
Yes
with my financial situation and it does not worry me
Unsure/No
Yes
that my financial situation does not worry my spouse/partner
Unsure/No
Yes
with my spending habits
Unsure/No
Yes
with my partner/spouse/dependents spending habits
Unsure/No
Yes
that I pay off credit cards each month
Unsure/No
Yes
that I will be able to acquire the new ( fill in the blank ) that I desire
Your answer
2. Retirement – I have…
a comfortable retirement
Unsure/No
Yes
determined my assets will outlast me
Unsure/No
Yes
defined written goals that I want to accomplish
Unsure/No
Yes
prioritized those goals
Unsure/No
Yes
determined how much of my assets I can spend without running out later
Unsure/No
Yes
determined that I am doing all that I want to in retirement
Unsure/No
Yes
3. Other life events – I currently have a plan as to how to…
purchase my next car without borrowing
Unsure/No
Yes
fund my grandchildren’s education (answer if you intend to or leave blank)
Unsure/No
Yes
help my family in ways I desire
Unsure/No
Yes
benefit those charities important to me (answer if important or leave blank)
Unsure/No
Yes
repair/upgrade my home as needed
Unsure/No
Yes
4. Investments – I am confident…
my investments provide adequate income
Unsure/No
Yes
my investments adequately reflect my risk tolerance/capacity
Unsure/No
Yes
my investments are properly diversified
Unsure/No
Yes
I know what the costs and fees are to my portfolio
Unsure/No
Yes
my portfolio has the highest return for the risk I am willing to take
Unsure/No
Yes
my portfolio is as tax efficient as possible
Unsure/No
Yes
if I died, my spouse/partner would know how to continue
Unsure/No
Yes
5. Risks - I am certain that I am adequately protected…
if my home were to burn to the ground
Unsure/No
Yes
if I were to be sued for a huge liability
Unsure/No
Yes
in the event of a health treatment costing $3 million
Unsure/No
Yes
in case of a 4 year long-term care stay 10 years from now
Unsure/No
Yes
6. Estate Planning – I am certain that my current estate planning documents will…
minimize conflicts and bickering in my family at my death
Unsure/No
Yes
minimize estate tax as much as legally possible
Unsure/No
Yes
not require modification when the Estate Tax laws change
Unsure/No
Yes
make it difficult to have my final wishes disputed by others
Unsure/No
Yes
make transfer of assets to my heirs as effortlessly as possible
Unsure/No
Yes
keep estate administrative costs as low as possible
Unsure/No
Yes
make it easy for me to be cared for if I become incapacitated
Unsure/No
Yes
assure my life support decisions will be followed without a legal battle
Unsure/No
Yes
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