Family QuestionnaireStep 1 of 250%How did you originally hear about us?Taxes in Retirement WebinarSocial Security WebinarWeb SearchFamily/FriendKTAR News 92.3 FMKKNT (The Patriot) 960 AMKPXQ (Faith Talk) 1360 AMKXXT (Family Values) 1010 AMKFYI (News Talk) 550 AMKVOI (The Voice) 1030 AMKQNA (News/Sports) 1030 AMKBTK (The Big Talker) 97.1 FMKFYR (Bismarck) 550 AMKOTA (Rapid City) 1380 AMWDAY (Fargo) 970 AMKBUL (Billings) 970 AMOtherIf other, please explain:Have you heard John’s radio show “Rethink Your Money with Keystone Wealth Partners?” Yes No UnsureHave you visited our website www.KeystoneWealthPartners.com? Yes No UnsureAre you currently a client of Keystone Law Firm? Yes No UnsureHave you listened to John's podcast "Dropping F-Bombs: Faith. Family. Finance. Football?" Yes No UnsureIf Keystone Wealth Partners did not exist, whom would you go to for financial advice?What is your biggest concern at this time?Total amount saved for retirementToday's Date(Required) MM slash DD slash YYYY Name(Required) First Last NicknameDate of Birth(Required) MM slash DD slash YYYY Age(Required)Email Address(Required) Cell Phone(Required)Home PhoneBusiness PhoneRetired(Required) Yes NoActual or Planned Year of Retirement(Required) MM slash DD slash YYYY Most Recent/Current Employment(Required)Years of Service(Required)Occupation(Required)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have a spouse?(Required) I have a spouse I do not have a spouseSpouses Name(Required) First Last NicknameDate of Birth(Required) MM slash DD slash YYYY Age(Required)Email Address Cell PhoneHome PhoneBusiness PhoneRetired(Required) Yes NoActual or Planned Year of Retirement(Required) MM slash DD slash YYYY Most Recent/Current EmploymentYears of Service(Required)Occupation(Required) Address same as spouseAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Number of ChildrenNumber of GrandchildrenPlease check for yes: Do you have a Financial Adviser? Do you have an attorney? Do you have an accountant? Do you have a will or trust? Do you want to leave money to your children? Do you currently own your home? Do you have any income from real estate? Do you expect to care for a child or parent? Do you have a pension, 401k, IRA? Do you have life insurance? Do you have long-term care protection? Have you had problems with a stockbroker?Financial Planning ObjectivesPlease select a number according to your level of concern (1 being the least and 10 being the most).Out-living my money 1 2 3 4 5 6 7 8 9 10Increasing current income 1 2 3 4 5 6 7 8 9 10Reducing current income taxes 1 2 3 4 5 6 7 8 9 10Safety of principal 1 2 3 4 5 6 7 8 9 10Maximize investment return 1 2 3 4 5 6 7 8 9 10Safety retirement money 1 2 3 4 5 6 7 8 9 10Safety non-retirement money 1 2 3 4 5 6 7 8 9 10Estate planning 1 2 3 4 5 6 7 8 9 10Rising healthcare 1 2 3 4 5 6 7 8 9 10Long term care 1 2 3 4 5 6 7 8 9 10Δ
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