Retirement Income Evaluator. Fill out and submit to me So I can provide you with an in depth look at your Retirement Income Scenario.

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MEMBER: NYSE, FINRA, SIPC • REF. 124386 • RETIREMENT INCOME EVALUATION QUESTIONNAIRE • PAGE 1
W E A L T H M A N A G E M E N T
Reti rement Income Evaluation
client information
Personal Information
Client Co-Client
Title
First Name
Last Name
Social Security #
Birth Date
Gender
Marital Status
Citizenship
Contact Information
Client Co-Client
Home Telephone
Business Telephone
Cellular Telephone
Fax
E-mail
Address
Client Co-Client
Address Line 1
Street
City
State
Zip Code
Country
Filing Status
 Single  Married/Jointly  Married/Separately
Salary
Specify the gross income numbers and the average annual increase of
your salary, if applicable.
Client Co-Client
Current Annual Salary $ $
Average Salary Increase $ $
Estimated Retirement Income
Client Co-Client
Annual Social
Security Benefit ($)
Annual Pension
Benefit ($)
Immediate Annuity
Fixed/Variable
Annuities
Income from Real
Estate
Business/Trust
Income
Other Income
Tax Rates
If you choose, you may indicate different tax rates in the table below for
Before Retirement and During Retirement.
Before Retirement During Retirement
Average Federal Tax Rate % %
Average State Tax Rate % %
This four-page document will help you gather basic information about your taxes, income sources, assets,
expenses and risk tolerance needed to complete your Retirement Income Evaluation. Please provide as
much information as possible in each section. In some cases, it may be necessary to provide estimates or
assumptions. If more room is needed, please feel free to attach a separate sheet of information. In order
for your Financial Advisor to provide the most effective and accurate analysis, we recommend that you
provide statements for any accounts held outside of Janney. Your Janney Financial Advisor will contact you
to clarify the information that you have provided and to collect any missing data.

2. Liquid Assets
Balances Client Co-Client
Checking
Savings
Money Market
CDs
Investment Accounts (Please list account type, e.g. general/IRA)
Investment Account 1
Account Name
Owner
Account Type
Current Balance
Annual Contributions Start Age End Age
Before Taxes $
After Taxes $
Check Current Allocation (if known)  40% Fixed Income, 60% Equity
 100% Cash  30% Fixed Income, 70% Equity
 80% Fixed Income, 20% Equity  10% Fixed Income, 90% Equity
 60% Fixed Income, 40% Equity  100% Equity
Investment Account 2
Account Name
Owner
Account Type
Current Balance
Annual Contributions Start Age End Age
Before Taxes
After Taxes
Check Current Allocation (if known)  40% Fixed Income, 60% Equity
 100% Cash  30% Fixed Income, 70% Equity
 80% Fixed Income, 20% Equity  10% Fixed Income, 90% Equity
 60% Fixed Income, 40% Equity  100% Equity
Investment Account 3
Account Name
Owner
Account Type
Current Balance
Annual Contributions Start Age End Age
Before Taxes
After Taxes
Check Current Allocation (if known)  40% Fixed Income, 60% Equity
 100% Cash  30% Fixed Income, 70% Equity
 80% Fixed Income, 20% Equity  10% Fixed Income, 90% Equity
 60% Fixed Income, 40% Equity  100% Equity
Investment Account 4
Account Name
Owner
Account Type
Current Balance
Annual Contributions Start Age End Age
Before Taxes
After Taxes
Check Current Allocation (if known)  40% Fixed Income, 60% Equity
 100% Cash  30% Fixed Income, 70% Equity
 80% Fixed Income, 20% Equity  10% Fixed Income, 90% Equity
 60% Fixed Income, 40% Equity  100% Equity
Investment Account 5
Account Name
Owner
Account Type
Current Balance
Annual Contributions Start Age End Age
Before Taxes
After Taxes
Check Current Allocation (if known)  40% Fixed Income, 60% Equity
 100% Cash  30% Fixed Income, 70% Equity
 80% Fixed Income, 20% Equity  10% Fixed Income, 90% Equity
 60% Fixed Income, 40% Equity  100% Equity
Other Assets
Real Estate Trust Business Other
Owner
Value
Original Loan Amount
Loan Start Year
Loan Interest Rate
Remaining Loan Bal.
Payment Amount
Payment Frequency
Estimated Sale Price
Estimated Sale Year
Retirement Goals (Please see Living Expenses Budget Planner)
Desired Annual Income NEED $
Desired Annual Income WANT $
Client Co-Client
Estimated
Retirement Age
Estimated Life
Expectancy
How Much Do You
Want to Leave as a
Legacy?
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3. Annual Living Expenses Budget Planner
Expense Amount Type Start Age End Age
(Please attach a separate sheet if more space is required.) $0,000 NEED WANT Optional
Mortgage  
Utilities  
Groceries  
Travel  
Hobbies  
Help pay for college for grandchildren  
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Additional Notes
You can use this section to provide any additional information you feel may be relevant to your Financial Advisor.
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4. Risk Profile (Please choose the answer that best describes you.)
1. What is your primary investment objective?
Preservation of Capital (You are willing to accept lower returns to avoid losses) (3)
Income (You are primarily looking for income from your investment portfolio, through interest and dividends) (4)
Growth & Income (You would like to generate income in your portfolio but are willing accept some risk to increase your overall portfolio) (5)
Growth of Capital (You are seeking market returns and can tolerate a moderate level of risk) (6)
High Potential Returns (You are seeking above-average market returns and are willing to accept an above-average level of risk) (7)
2. How would you categorize your prior investment experience?
Little Experience (You have little or some knowledge, not in-depth) (1)
Moderate/Somewhat Experienced (Familiar with basic investments) (2)
Experienced (You possess knowledge of major asset classes, sources of risk and are well versed in investment and portfolio process) (3)
3.Understanding that investment returns may vary between accounts,taken as a whole,what is your expected return for your overall investment portfolio?
Low (Your portfolio returns are less important than preservation of capital) (1)
Conservative (Your portfolio returns should match inflation rates) (2)
Moderate (Your portfolio returns should be aligned with primary benchmark returns) (3)
High (Your portfolio returns should be in excess of primary benchmark returns) (4)
Very High (Your portfolio returns should be matched with speculative returns) (5)
4.Which statement below best describes your attitude about the trade-off between short-term risk and the possibility of achieving your long-term goals?
Risk is More Important than Return (Avoiding short-term losses is more important to you than achieving your long-term investment goals) (1)
Risk and Return Are Equally Important (You are equally concerned with avoiding short-term losses and meeting your long-term goals) (3)
Return is More Important than Risk (You can accept short-term losses to maximize the potential that you will achieve your long-term goals) (5)
Client Signature Date Client Signature Date
5. How would you categorize yourself as an investor?
Very Conservative (0)
Conservative (1)
Moderate (3)
Aggressive (4)
Speculative (5)
6. What percent of your overall net worth is represented by your investment portfolio?
75% or Greater (1)
25% – 75% (2)
25% or Less (3)
7.When do you anticipate withdrawing substantial and recurring portions of your assets (greater than 5%)?
Within 2 Years (1)
2 Years – 5 Years (2)
5 Years – 10 Years (3)
10 Years or Longer (4)
Total
Signature(s)
Circle One
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This scale can be used to determine an
appropriate model portfolio. The investment
portfolio recommended by your Financial
Advisor may differ. Your Financial Advisor will
determine your actual investment portfolio based
on a combination of your risk profile, stated
goals and other factors that make up your total
financial picture.
Use the scale below to find your
appropriate Model Portfolio.
Model Portfolio Min. Max.
Wealth Preservation & Income 8 11
Wealth Appreciation 12 20
Wealth Accumulation 21 32