Confidential Lifestyle & Financial Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Confidential Lifestyle & Financial Questionnaire To begin this process, we need you to consider the following points and then complete and submit this form. If you are completing this form as a couple, we ask that you discuss the questions together and provide a collaborated response. Your Personal Details & Resources By clearly identifying your personal details and resources you will assist us understand your current financial situation Your Objectives By identifying your Objectives, you will allow us to focus your resources on the range of outcomes you would like to achieve. Your Priorities By prioritising your Objectives, you will assist us work towards those outcomes that are most important to you. Additional Information By providing us with any additional information you might think is relevant, we will be able to help identify hurdles that may impede you achieving your lifestyle and financial objectives. Privacy Statement, Acknowledgment and Tax File Number Authorisation By reading and signing these sections, you will assist us in designing a plan around the information provided within this questionnaire. Your personal details Client 1 - Given Name(s) * Client 1 - Surname * Client 1 - Mother's Maiden Name Client 1 - Gender MaleFemaleOther Client 1 - Country of Residence - Select - Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Austria Australia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bougainville Brazil British Indian Ocean British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Islands Cayman Islands Central African Republic Chad Chile China (Hong Kong) China (Macau) Colombia Comoros Congo (Democratic Republic of) Congo (Republic of) Cook Islands Costa Rica Cote d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (Democratic Peoples Rep) Korea (Republic of) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts & Nevis Saint Lucia Saint Martin Saint Pierre & Miquelon Saint Vincent Samoa San Marino Sao Tomé & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Islands Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of GB & NI United States of America Uruguay US Virgin Islands Uzbekistan Vanuatu Venezuela Vietnam Wallis & Futuna Islands Yemen Zambia Zimbabwe Client 1 - Place of Birth Client 1 - Date of Birth * Client 1 - Marital Status * SingleMarriedDefactoOther Client 1 - If you selected 'Other' above, please specify: Client 2 - Given Name(s) Client 2 - Surname Client 2 - Mother's Maiden Name Client 2 - Gender MaleFemale Client 2 - Country of Residence - Select - Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo (Republic of the) Congo (Democratic Republic of the) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Romania Russia Rwanda St. Kitts and Nevis St. Lucia St. Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States of America (USA) Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Zambia Zimbabwe Client 2 - Place of Birth Client 2 - Date of Birth Client 2 - Marital Status SingleMarriedDefactoOther Client 2 - If you selected other, please specify: Residence Residential Address * Residential Suburb * Residential Postcode * Postal Address – If different from residential address Postal Address Postal Suburb Postal Postcode Contact Details Client 1 - Phone (Mobile) * Client 1- Phone (Home) Client 1 - Phone (Work) Client 1 - Email * Client 2 - Phone (Mobile) Client 2 - Phone (Home) Client 2 - Phone (Work) Client 2 - Email Children Given Name(s) of Child 1 Age of Child 1 Date of Birth of Child 1 Financially Dependent Child 1 YesNo Given Name(s) of Child 2 Age of Child 2 Date of Birth of Child 2 Financially Dependent Child 2 YesNo Given Name(s) of Child 3 Age of Child 3 Date of Birth of Child 3 Financially Dependent Child 3 YesNo Client 1 Occupation Client 1: Occupation Client 1: Name of Employer Client 1: Employment Status - Select - Full time employee Self employed Contractor Part time employee Home Manager Retired Semi Retired Unemployed Client 1: Remuneration Package (if applicable) Client 2 Occupation Client 2: Occupation Client 2: Name of Employer Client 2: Employment Status - Select - Full time employee Self employed Contractor Part time employee Home Manager Retired Semi Retired Unemployed Client 2: Remuneration Package (if applicable) Client 1 - Health & Insurance Client 1 - Private Health Cover YesNo Client 1 - Type of Private Health Cover HospitalAncilliarySpecial extras Client 1 - Health Concerns YesNo Client 1 - Health Concerns Details Client 1 - Are you a smoker? YesNo Client 1 - Do you have a will? YesNo Client 1 - Do you have a Power of Attorney YesNo Client 1 - What Type of Power of Attorney do you have? Enduring/ FinancialMedical Client 1 - Do you have Life Insurance? YesNo Client 1 - If so, what is the level of your Death Cover? Client 1 - Level of Total and Permanent Disability Cover Client 1 - Level of Trauma and Critical Illness Cover Client 1 - Level of Monthly Income Protection Cover Client 2 - Health & Insurance Client 2 - Private Health Cover YesNo Client 2 - Health Concerns YesNo Client 2 - Health Concerns Details Client 2 - Are you a smoker? YesNo Client 2 - Do you have a will? YesNo Client 2 - Do you have a Power of Attorney YesNo Client 2 - What Type of Power of Attorney do you have? Enduring/ FinancialMedical Client 2 - Do you have Life Insurance? YesNo Client 2 - If so, what is the level of your Death Cover? Client 2 - Level of Total and Permanent Disability Cover Client 2 - Level of Trauma and Critical Illness Cover Client 2 - Level of Monthly Income Protection Cover Assets (Please use approximate figures) Lifestyle Assets Family Home * Holiday Home Other (eg: Boat, Caravan, Etc) A - Total Lifestyle Assets Home and Personal Loans Outstanding Credit Card/Personal Loans * Home Mortgage Balance * B - Total Non Deductible Debt Client 1 - Investments Client 1 - At Call Bank Accounts * Client 1 - Term Deposits * Client 1 - Share Portfolio (list required) * Client 1 - Rental Properties (list required) * Client 1 - Other Asset 1 (financials required) Client 1 - Other Asset 2 (financials required) Client 1 - Total Investments Client 2 - Investments Client 2 - At Call Bank Accounts Client 2 - Term Deposits Client 2 - Share Portfolio (list required) Client 2 - Rental Properties (list required) Client 2 - Other Asset 1 (financials required) Client 2 - Other Asset 2 (financials required) Client 2 - Total Investments Loans Deductible Loans D - Total Investment Loans Client 1 - Superannuation & Pension Client 1 - Employer Funds Client 1 - Personal Funds Client 1 - Self Managed Super Fund * Client 1 - Total Superannuation/ Pensions Client 2 - Superannuation & Account Based Pensions Client 2 - Employer Funds Client 2 - Personal Funds Client 2 - Self Managed Super Fund Client 2 - Total Superannuation/ Pensions Client 1 - What do you earn each year before tax? Client 1 - Salary * Client 1 - Other Income 1 Client 1 - Other Income 2 Client 1 - Total Income before Tax * Client 2 - What do you earn each year before tax? Client 2 - Salary Client 2 - Other Income 1 Client 2 - Other Income 2 Client 2 - Total Income before Tax Annual cost of living * How much do you estimate that you save each year? Annual Savings * What Expenditure do you have planned? Amount: Motor car /motorbike ? * When: Motor car /motorbike ? (approximate) How often afterwards: Motor car /motorbike ? Amount: Renovations? * When: Renovations? (approximate) Amount: Holiday? * When: Holiday? - Select - More than once a year Yearly Every 2 Years Every 3 Years Every 4 Years Every 5 Years How often afterwards: Holiday? Amount: Other? * When: Other? (approximate) How often afterwards: Other? Total Planned Expenditure Objectives & Priorities What are your objectives and priorities? * Additional Information What are the main reasons for contacting Collins House? * When do you realistically plan to retire from full time work (age or year)? * When do you plan to retire from all forms of paid employment (age or year)? * In retirement, what regular income (in today’s dollar) do you need to cover your cost of living on a monthly basis after tax? * How much money do you require to be available at short notice for unforeseen expenses? * Which assets do you wish to leave to your family and/or charity if any? * Are there any issues or events that are confronting you at the moment? * Supply additional documentation using the file upload by clicking 'Browse' Supply additional documentation using the file upload by clicking 'Browse' Privacy Statement Your personal information is collected for the purpose of providing you with financial planning advice. We need to conduct an appropriate investigation of your financial and personal situation and your particular needs and objectives to enable us to make recommendations to you on a reasonable basis. If you choose not to provide the information requested by us, we may not be able to provide you with the advice you require. We may disclose information about you to annuity providers in the process of preparing our financial planning advice. You are entitled to obtain access to the information collected by contacting Collins House Private Wealth or your adviser. You need to be aware that if you provide information to Collins House Private Wealth on behalf of another person, it is your responsibility to inform them of your disclosure and to make them aware that they may obtain access to their information held by Collins House Private Wealth. Your Acknowledgment I/We acknowledge that, by completing and authorising this overview, its contents are correct to the best of my/our knowledge and that its role is to enable Collins House Private Wealth to undertake an initial assessment of my/our situation. I confirm the details provided are accurate to the best of my knowledge * Today's Date * Tax File Number Authorisation I/We give permission for my/our tax file number/s, as provided below, to be forwarded to financial institutions as requested or as necessary. Client 1 Name * Client 1 Tax File Number * Client 1 TFN Authorisation * YesNo Client 2 Name Client 2 Tax File Number Client 2 TFN Authorisation YesNo Optional Additional Information Confirm that you are not a bot *
