Personal Financial Data Form Name Date...Page | 3 ATHENS - 297 PRINCE AVE., SUITE 15 BOTTLEWORK S,...

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WWW.FULLCUPFINANCIAL.COM ATHENS - 297 PRINCE AVE., SUITE 15 BOTTLEWORKS, ATHENS, GEORGIA 30601 - 706-395-0757

ATLANTA - 2900 PACES FERRY RD., SUITE B-104, ATLANTA, GEORGIA - 770-433-3030 Securities and advisory services offered through Cetera Advisors LLC, Member FINRA, SIPC, a broker/dealer and a Registered

Investment Advisor. Cetera is under separate ownership from any other named entity.

Personal Financial Data Form

Name: ___________________________________________________ Date: _______________________

Anything of value is worth an investment of thought, planning, and time. To provide the most productive and meaningful financial evaluation, your effort in completing this form is requested.

This Personal Financial Data Form allows us to address the Five Key Principles of Financial Planning, including the Protection of Assets, Estate Planning, Retirement Income, Tax Planning, and Investment Management. In addition to the traditional areas of financial planning, this form allows us to address the Diversification of Advisors and Custodians, Legacy Planning, and Charitable Giving.

The information requested gives your Full Cup Financial Advisor a better understanding of your current financial picture in an attempt to assist you in addressing which direction you want your financial journey to go. Further, in light of the Five Key Principles of Financial Planning, it will aid in making recommendations related to your specific personal concerns and objectives.

Please complete the Personal Financial Data Form and return it to:

Chris Foster Full Cup Financial 297 Prince Avenue Suite 15 Bottleworks Athens, Georgia 30601

or by Email to: [email protected]

or upload into your Client Portal through AdviceWorks: www.client.adviceworks.net

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Personal Information

Client A: Client B:

First Name: __________________________________ First Name:__________________________________

Middle Name: ________________________________ Middle Name: _______________________________

Last Name: ___________________________________ Last Name: __________________________________

Suffix: _______________________________________ Suffix: ______________________________________

Preferred Name: ______________________________ Preferred Name: _____________________________

Birthday: __________________ Age: ___________ Birthday: __________________ Age: __________

Sex: ________________________________________ Sex: _______________________________________

Marital Status: ________________________________ Marital Status: _______________________________

Cell Phone: __________________________________ Cell Phone: __________________________________

Email: _______________________________________ Email: ______________________________________

Preferred Contact Method: ______________________ Preferred Contact Method: _____________________

City & State of Birth: ___________________________ City & State of Birth: __________________________

Home Address: Home Address: Same as Client A? ______

___________________________________________ ___________________________________________

City, State, Zip: _______________________________ City, State, Zip: _______________________________

Mailing Address: Same as Home Address? ______ Mailing Address: Same as Client A? ______

___________________________________________ ___________________________________________

City, State, Zip: _______________________________ City, State, Zip: _______________________________

Driver’s License #: _____________________________ Driver’s License #: ____________________________

DL Exp: _______________ DL Iss: ________________ DL Exp: ______________ DL Iss: _______________

State Driver’s License Issued: ____________________ State Driver’s License Issued: ____________________

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Employment InformationClient A: Client B:

Employment Status: ___________________________ Employment Status: ___________________________

Occupation: __________________________________ Occupation: _________________________________

Employer: ___________________________________ Employer: ___________________________________

Employer Address: Employer Address:

___________________________________________ ___________________________________________

Employer City & State: _________________________ Employer City & State: _________________________

Work Phone: _________________________________ Work Phone: ________________________________

If Retired, Previous Occupation & Employer: If Retired, Previous Occupation & Employer:

Prev. Occ: ___________________________________ Prev. Occ: ___________________________________

Prev. Emp: ___________________________________ Prev. Emp: __________________________________

Children If additional space needed, please complete on blank sheet and attach

Child #1: Child #2:




Sex: ________________________________________ Sex: _______________________________________

Child of: _____________________________________ Child of: ____________________________________

Child #3: Child #4:




Sex: ________________________________________ Sex: _______________________________________

Child of: _____________________________________ Child of: ____________________________________

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Tax Planning

For this section, please refer to your most recent Tax Return. Complete as household.

Tax Filing Status: _____________________________________________________________________________

Name of Tax Preparer: _________________________ Tax Year: ____________ Fee: ________________

Line Items from Tax Form 1040:

Line 1 - Wages, Salaries, Etc.: ____________________ Line 7a - Other Income: ________________________

Line 7b - Total Income: _________________________ Line 8a - Income Adjustments: __________________

Line 8b - Adjusted Gross Income: _________________ Line 9 - Stnd/Item Deductions: __________________

Line 11a - Total Deductions: _____________________ Line 11b - Taxable Income: _____________________

Estimated Tax Bracket: _________________________

Annual Income (Current and Future) If additional space needed, please complete on blank sheet and attach

Salaries, Pensions, Social Security, Annuities, Investments and Other

Owner Income Source

Annual Income

Survivor Benefit %

Income Start Date

Income Stop Date

% % % % % %

Social Security Information

For this section, please reference your most recent Social Security Statement. If you do not have a current statement, you can access it online by going to www.ssa.gov and create/sign in to your account to access it.

Client A: Client B:

Current Claim Status: __________________________ Current Claim Status: __________________________

If Benefits Unclaimed: If Benefits Unclaimed:

Primary Insurance Amount: ______________________ Primary Insurance Amount: ____________________

If Benefits Claimed: If Benefits Claimed:

Age In-Progress Claim Began: ____________________ Age In-Process Claim Began: ____________________

Current Monthly Benefit: _______________________ Current Monthly Benefit: ______________________

http://www.ssa.gov/

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Liquid Assets If additional space needed, please complete on blank sheet and attach

Checking, Savings, Cash, CD’s, Money Markets and Other Owner Account Type Institution Name Account Value

Investment Accounts If additional space needed, please complete on blank sheet and attach

Traditional IRAs, Rollover IRAs, Roth IRAs, Individual Accts, Joint Accts and Other Owner Account Type Institution Name Monthly Contribution Account Value

Employer Sponsored Retirements If additional space needed, please complete on blank sheet and attach

401(k), 403(b), SEP IRAs, SIMPLE IRAs, TSAs and Other Owner Account Type Institution Name Cont. % Match % Account Value % % % % % % % % % % % %

Custodial Accounts If additional space needed, please complete on blank sheet and attach

529s, UGMAs, UTMAs and Other Child Name Account Type Institution Name Monthly Contribution Account Value

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Real Estate If additional space needed, please complete on blank sheet and attach

Primary, 2nd Residence, Vacation Homes, Condos, Rental Properties, Farms and Other

Owner Property Type

Original Loan Amount + Improvements

Estimated Market Value

Mortgage Balance

Interest Rate

Monthly Payment (PITI)

% % % % % %

Liabilities / Debts If additional space needed, please complete on blank sheet and attach

Credit Cards, Auto Loans, Student Loans, Medical Loans and Other

Owner Debt Type

Current Balance

Interest Rate

Minimum Monthly Payment

Current Monthly Payment

% % % % % % % % % %

Life InsuranceClient A: Client B:

Own Life Insurance? ___________________________ Own Life Insurance?___________________________

Type of Life Insurance: _________________________ Type of Life Insurance: _________________________

If Term, Term Length: __________________________ If Term, Term Length: _________________________

Insurance Company: ___________________________ Insurance Company: __________________________

Coverage: __________ Cash Value: _____________ Coverage: ___________ Cash Value: ____________

Premium: ___________ Policy Date: ____________ Premium: ___________ Policy Date: ____________

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Long Term Care Insurance

Client A: Client B:

Own Long-Term Care Insurance? _________________ Own Long-Term Care Insurance? _________________


Benefit: ____________ Cash Value: _____________ Benefit: ____________ Cash Value: ____________

Premium: ___________ Policy Date: ____________ Premium: ___________ Policy Date: ____________

Disability Insurance

Client A: Client B:

Own Disability Insurance? _______________________ Own Disability Insurance? ______________________


Benefit: ____________ Policy Date: ____________ Benefit: ____________ Policy Date: ___________

Property and Casualty Insurance

Client A: Client B:


Total Liability Coverage: ________________________ Total Liability Coverage: ________________________

Uninsured Motorist Coverage: ___________________ Uninsured Motorist Coverage: ___________________

Umbrella Policies

Client A: Client B:

Own an Umbrella Policy? _______________________ Own an Umbrella Policy? _______________________

Total Coverage: _______________________________ Total Coverage: ______________________________

Health Insurance

Client A: Client B:

Describe Health Insurance Coverage and Premiums: Describe Health Insurance Coverage and Premiums:

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

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Estate Planning

Are you a Beneficiary of any known Inheritances? ___________________________________________________

If Yes, Please Describe:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Do you have a Will or Estate Plan? _______________________________________________________________

If Yes, what is the Approximate Date the Will or Estate Plan was Prepared? ______________________________

What is the Name of the Law Firm or Attorney who prepared your Will or Estate Plan?

_________________________________________________________________________________________

Who are Named as Fiduciaries in your Will or Estate Plan (i.e. Executor / Executrix, Trustees, etc.)?

_________________________________________________________________________________________

Do you have a Living Will and a Durable Power of Attorney? ___________________________________________

Do you have any “Special Needs” Children or Family Members? ________________________________________

Would you like any Charitable Organizations to receive a portion of your Estate upon your death? _____________

If Yes, what are the Names of the Charitable Organizations?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Briefly Describe your Estate Planning Objectives with Respect to your Heirs:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

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Retirement PlanningClient A: Client B:

Estimated Retirement Age: ______________________ Estimated Retirement Age: _____________________

Complete as Household

Goal Monthly Retirement Income: ________________ Current Monthly Expenses: _____________________

Major Financial Goals: Major Financial Goals:

1: __________________________________________ 1: _________________________________________

2: __________________________________________ 2: _________________________________________

3: __________________________________________ 3: _________________________________________

Major Financial Concerns: Major Financial Concerns:

1: __________________________________________ 1: _________________________________________

2: __________________________________________ 2: _________________________________________

3: __________________________________________ 3: _________________________________________

Risk Tolerance and Investment ObjectivesClient A: Client B:

Investment Objective: __________________________ Investment Objective: _________________________

Risk Tolerance: _______________________________ Risk Tolerance: _______________________________

Do you have any Investment Experience? ____________ Do you have any Investment Experience? __________

If yes, Select Invest. Type and Estimated No. of Years: If yes, Select Invest. Type and Estimated No. of Years:

Investment Type: Est. Years: Investment Type: Est. Years:

_________________________ ______________ _________________________ ______________

_________________________ ______________ _________________________ ______________

_________________________ ______________ _________________________ ______________

_________________________ ______________ _________________________ ______________

_________________________ ______________ _________________________ ______________

_________________________ ______________ _________________________ ______________

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Preferred Beneficiary Information If additional space needed, please complete on blank sheet and attach

At the time of my death, the primary beneficiaries named below will receive my assets. If all of my primary beneficiaries die before me, the contingent beneficiaries named below will receive my IRA assets.

Client A: Client B:

Beneficiary #1: Beneficiary #1:

Beneficiary Type: _____________ Share: _______ % Beneficiary Type: ____________ Share: _______ %



Date of Birth: ________________ Sex: __________ Date of Birth: _______________ Sex: __________

Relationship: _________________________________ Relationship: ________________________________



















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Client A - Risk Tolerance Questionnaire 1. When do you expect to begin withdrawing money from your investment account?

Less than 2 years 2 years 3 to 4 years 5 to 7 years 8 to 10 years More than 10 years

2. Once you begin withdrawing money from your investment account, how long do you expect the withdrawals to last?

I plan to take a lump sum distribution 1 to 4 years 5 to 7 years 8 to 10 years More than 10 years

3. Which of the following choices best reflects your attitude towards inflation and risk?

My main goal is to avoid loss, even though I may only keep pace with inflation. My main goal is to earn slightly more than inflation, while taking on a low level or risk. My main goal is to increase my portfolio’s value. Therefore, I am willing to accept short-term losses, but I

am not comfortable with extreme performance shifts that may be experienced in the most aggressive portfolios.

My main goal is to maximize my portfolio value, and I am willing to take on more extreme levels of risk and performance shifts in my portfolio to do so.

4. The table below presents a hypothetical worst-case loss, expected gain, and best-case gain of five sample portfolios over a one-year period with an initial $100,000 investment:

BEST CASE EXPECTED GAIN WORST CASE PORTFOLIO 1 $111,300 $104,300 $90,200 PORTFOLIO 2 $114,500 $105,300 $84,700 PORTFOLIO 3 $118,500 $106,200 $78,700 PORTFOLIO 4 $123,100 $107,100 $72,800 PORTFOLIO 5 $126,700 $107,900 $68,200

Which portfolio would you prefer to hold?

Portfolio 1 Portfolio 2 Portfolio 3 Portfolio 4 Portfolio 5

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5. Investing involves a trade-off between risk and return. Which statement best describes your investment goals?

Protect the value of my account. In order to minimize the chance for loss, I am willing to accept the lower long-term returns provided by conservative investments.

Keep risk to a minimum while trying to achieve slightly higher returns than the returns provided by investments that are more conservative.

Focus more on the long-term investment returns. Long-term growth is equally as important as managing portfolio risk.

Maximize long-term investment returns. I am willing to accept large and sometimes dramatic short-term fluctuations in the value of my investment.

6. Historically, markets have experienced downturns, both short-term and prolonged, followed by market recoveries. Suppose you owned a well-diversified portfolio that fell by 20% (i.e. $1,000 initial investment would now be worth $800) over a short period, consistent with the overall market. Assuming you still have 10 years until withdrawals, how would you react?

I would not change my portfolio. I would wait at least one year before changing to options that are more conservative. I would wait at least three months before changing to options that are more conservative. I would immediately change to options that are more conservative.

7. The following chart shows the hypothetical best and worst results of five sample portfolios over a one-year holding period. Note that the portfolio with the highest upside also has the largest downside.


Portfolio A Portfolio B Portfolio C Portfolio D Portfolio E

8. I am comfortable with investments that may frequently experience large declines in value if there is a potential for higher returns. What is your view regarding this statement?

Strongly disagree Disagree Somewhat agree Agree Strongly Agree

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Client B - Risk Tolerance Questionnaire 1. When do you expect to begin withdrawing money from your investment account?

Less than 2 years 2 years 3 to 4 years 5 to 7 years 8 to 10 years More than 10 years

2. Once you begin withdrawing money from your investment account, how long do you expect the withdrawals to last?

I plan to take a lump sum distribution 1 to 4 years 5 to 7 years 8 to 10 years More than 10 years

3. Which of the following choices best reflects your attitude towards inflation and risk?

My main goal is to avoid loss, even though I may only keep pace with inflation. My main goal is to earn slightly more than inflation, while taking on a low level or risk. My main goal is to increase my portfolio’s value. Therefore, I am willing to accept short-term losses, but I

am not comfortable with extreme performance shifts that may be experienced in the most aggressive portfolios.

My main goal is to maximize my portfolio value, and I am willing to take on more extreme levels of risk and performance shifts in my portfolio to do so.

4. The table below presents a hypothetical worst-case loss, expected gain, and best-case gain of five sample portfolios over a one-year period with an initial $100,000 investment:

BEST CASE EXPECTED GAIN WORST CASE PORTFOLIO 1 $111,300 $104,300 $90,200 PORTFOLIO 2 $114,500 $105,300 $84,700 PORTFOLIO 3 $118,500 $106,200 $78,700 PORTFOLIO 4 $123,100 $107,100 $72,800 PORTFOLIO 5 $126,700 $107,900 $68,200


Portfolio 1 Portfolio 2 Portfolio 3 Portfolio 4 Portfolio 5

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5. Investing involves a trade-off between risk and return. Which statement best describes your investment goals?

Protect the value of my account. In order to minimize the chance for loss, I am willing to accept the lower long-term returns provided by conservative investments.

Keep risk to a minimum while trying to achieve slightly higher returns than the returns provided by investments that are more conservative.

Focus more on the long-term investment returns. Long-term growth is equally as important as managing portfolio risk.

Maximize long-term investment returns. I am willing to accept large and sometimes dramatic short-term fluctuations in the value of my investment.

6. Historically, markets have experienced downturns, both short-term and prolonged, followed by market recoveries. Suppose you owned a well-diversified portfolio that fell by 20% (i.e. $1,000 initial investment would now be worth $800) over a short period, consistent with the overall market. Assuming you still have 10 years until withdrawals, how would you react?

I would not change my portfolio. I would wait at least one year before changing to options that are more conservative. I would wait at least three months before changing to options that are more conservative. I would immediately change to options that are more conservative.

7. The following chart shows the hypothetical best and worst results of five sample portfolios over a one-year holding period. Note that the portfolio with the highest upside also has the largest downside.


Portfolio A Portfolio B Portfolio C Portfolio D Portfolio E

8. I am comfortable with investments that may frequently experience large declines in value if there is a potential for higher returns. What is your view regarding this statement?

Strongly disagree Disagree Somewhat agree Agree Strongly Agree

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WWW.FULLCUPFINANCIAL.COM ATHENS ‐ 297 PRINCE AVE., SUITE 15 BOTTLEWORKS, ATHENS, GEORGIA 30601 ‐ 706‐395‐0757

ATLANTA ‐ 2900 PACES FERRY RD., SUITE B‐104, ATLANTA, GEORGIA ‐ 770‐433‐3030 Securities and advisory services offered through Cetera Advisors LLC, Member FINRA, SIPC, a broker/dealer and a Registered


Asset Summary

Liquid Assets: Client A Client B Joint

Liquid Assets: ______________________ ____________________ ______________________

Total Liquid Assets: ______________________

Invested Assets: Client A Client B Joint

Qualified IRAs: ______________________ ____________________ ______________________

Roth IRAs: ______________________ ____________________ ______________________

Non‐Qualified Accts: ______________________ ____________________ ______________________

Retirement Accts: ______________________ ____________________ ______________________

Insurance Cash Values: ______________________ ____________________ ______________________

Sum of Invested Assets: ______________________ ____________________ ______________________

Total Invested Assets: ______________________

Real Estate Assets: Market Value Mortgage Balance Equity

Primary Residence: ______________________ ____________________ ______________________

Non‐Primary Real Estate: ______________________ ____________________ ______________________

Total Non‐Primary Equity: ______________________

Debt & Liability Summary

Debts / Liabilities: Client A Client B Joint

Debts / Liabilities: ______________________ ____________________ ______________________

Total Debts / Liabilities: ______________________

Net Worth Summary

Net Worth: Client A Client B Joint

Total Assets: ______________________ ____________________ ______________________

______________________ ____________________ ______________________

______________________ ____________________ ______________________

Total Debts / Liabilities:

Liquid Net Worth:

Household Net Worth: ______________________

Personal Financial Data Form Name Date...Page | 3 ATHENS - 297 PRINCE AVE., SUITE 15 BOTTLEWORK S,...

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