Family Legacy Journey – Survey Step 1 of 6 16% There are 6 sections in this confidential process. You will be automatically redirected to the next step, as you complete the previous one. At the end, you will see a confirmation that your survey is complete.Before you begin, please collect the following so you can complete the process: - Employment information - Account information - Insurance information - Loan, mortgage, and credit card information - Real estate information - Estate planning documents If you gather all of your documents and statements now, this process should take you about an hour to complete.Personal & Contact InformationName (First, Middle Initial, Last)If married, Spouse Name (First, Middle Initial, Last)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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberCell Phone Number #1Cell Phone Number #2Email Email #2 Date of Birth or Age If married, Spouse Date of Birth or Age Are you employed?YesNoEmployer Name Employer City and State Position Title If you are married, is your spouse employed?YesNoSpouse Employer Name (if applicable) Spouse Employer City and State (if applicable) Spouse Position Title (if applicable) Do you have a financial advisor?YesNoFinancial Advisor Name/Company Financial Advisor Phone NumberDo you have an insurance representative (property/casualty)?YesNoInsurance Representative Name/Company Insurance Representative Phone NumberDo you have an estate planning attorney?YesNoEstate Planning Attorney Name/Company Estate Planning Attorney Phone NumberDo you have any other attorneys?YesNoOther Attorney Name/Company Other Attorney Phone NumberDo you have an accountant?YesNoAccountant Name/Company Accountant Phone NumberDo you have any other trusted advisors?YesNoTrusted Advisor Name/Company Trusted Advisor Phone NumberName of Financial Advisor Which advisory team do you work with?* Bernie Bostwick or Lenny Marsch Bob Kauffman, Adrian Young, or Dan Bailey Dirk Olds, Merri Sturtevant, or Matt Diers Angie Shea or Curtis Musser I'm not sure Who referred you to participate in the Family Legacy Journey? AssetsAccounts – All questions apply for you and/or your spouse.Do you have a Traditional (pre-tax) IRA?NoYesI don't knowTraditional (pre-tax) IRA Name on Account Traditional (pre-tax) IRA Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherTraditional (pre-tax) IRA Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherTraditional (pre-tax) IRA Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Traditional (pre-tax) IRA?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Traditional (pre-tax) IRA(s).Do you have a Roth IRA?NoYesI don't knowRoth IRA Name on Account Roth IRA Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherRoth IRA Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherRoth IRA Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Roth IRA?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Roth IRA(s).Do you have a SEP IRA?NoYesI don't knowSEP IRA Name on Account SEP IRA Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherSEP IRA Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherSEP IRA Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another SEP IRA?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional SEP IRA(s).Do you have a SIMPLE IRA?NoYesI don't knowSIMPLE IRA Name on Account SIMPLE IRA Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherSIMPLE IRA Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherSIMPLE IRA Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another SIMPLE IRA?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional SIMPLE IRA(s).Do you have a retirement plan through a current or former employer?NoYesI don't knowRetirement Plan Name on Account Retirement Plan Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherRetirement Plan Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherRetirement Plan Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Retirement Plan?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Retirement Plan(s).Do you have a non-retirement brokerage or investment account?NoYesI don't knowNon-retirement brokerage or investment account Name on Account Non-retirement brokerage or investment account Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another non-retirement brokerage or investment account?NoYesName on Account and Account Number (last 4 digits only)for additional non-retirement brokerage or investment account(s).Do you have a bank CD?NoYesI don't knowBank CD Name on Account Bank CD Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Bank CD?NoYesName on Account and Account Number (last 4 digits only) for additional Bank CD(s).Do you have a bank checking account?NoYesBank checking account Name on Account Bank checking account Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Bank checking account?NoYesName on Account and Account Number (last 4 digits only) for additional Bank checking account(s).Do you have a bank savings account?NoYesBank savings account Name on Account Bank savings account Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Bank savings account?NoYesName on Account and Account Number (last 4 digits only) for additional Bank savings account(s). Assets (continued)Do you have accounts with any other financial institutions?NoYesOther account Name on Account, beneficiary, and account number (last 4 digits only)Do you have stock options, or a stock purchase plan?NoYesI don't knowStock options, or a stock purchase plan Name on Account Stock options, or a stock purchase plan Account Number (last 4 digits only)Please enter a number from 0 to 9999.Do you (or your spouse) have another stock options, or a stock purchase plan?NoYesName on Account and Account Number (last 4 digits only) for additional stock options, or stock purchase plan(s).Do you have a custodial or educational savings account for your children or grandchildren?NoYesI don't knowCustodial or educational savings account Name on Account Custodial or educational savings account Beneficiary Custodial or educational savings account Account Number (last 4 digits only)Please enter a number from 0 to 9999.Do you (or your spouse) have another custodial or educational savings account?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional custodial or educational savings account(s).Do you have an annuity?NoYesI don't knowAnnuity Name on Account Annuity Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherAnnuity Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherAnnuity Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another annuity?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional annuity(ies).InsuranceAll questions apply for you and/or your spouse.Do you have a life insurance policy?NoYesI don't knowLife insurance policy Name on Account Life Insurance Primary Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherLife Insurance Contingent Beneficiary100% spouse100% split between all children100% to one or more nonprofitsSplit between spouse and childrenSplit between spouse and nonprofitSplit between children and nonprofitOtherLife insurance policy Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Life insurance policy?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Life insurance policy(ies).Do you have a disability insurance policy?NoYesI don't knowDisability insurance policy Name on Account Disability insurance policy Beneficiary Disability insurance policy Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Disability insurance policy?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Disability insurance policy(ies).Do you have a long-term care insurance policy?NoYesI don't knowLong-term care insurance policy Name on Account Long-term care insurance policy Beneficiary Long-term care insurance policy Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Long-term care insurance policy?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Long-term care insurance policy(ies).Do you have a health insurance policy?NoYesI don't knowHealth insurance policy Name on Account Health insurance policy Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Health insurance policy?NoYesName on Account, and Account Number (last 4 digits only) for additional Health insurance policy(ies).Do you have military retirement or survivor benefits?NoYesI don't knowMilitary retirement or survivor benefits Name on Account Military retirement or survivor benefits Beneficiary Military retirement or survivor benefits Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have another Military retirement or survivor benefits?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional Military retirement or survivor benefits.Do you have any other personal insurance policies?NoYesI don't knowOther Insurance Policy Name on Account Other Insurance Policy Beneficiary Other Insurance Policy Account Number (last 4 digits only)Please enter a number less than or equal to 9999.Do you (or your spouse) have any other insurance policies?NoYesName on Account, Beneficiary, and Account Number (last 4 digits only) for additional insurance policy(ies). Property / Accounts ReceivableAll questions apply for you and/or your spouse.Do you own your primary residence?NoYesDescription, value, and address of primary residence.Do you own real estate (other than your primary residence)?NoYesDescription, value, and address.Do you have personal property stored outside your primary residence?NoYesDescription and location of personal property stored outside your primary residence.Do you own any antiques or other personal property that may require special attention?NoYesDescription.Does anyone owe you a formal personal debt (promissory note, mortgage, etc.)?NoYesDescription of formal personal debt.LiabilitiesDo you owe money on an automobile loan?NoYesAutomobile Loan Name on Account Automobile Loan Account Number (last 4 digits only) Do you owe money on a home mortgage?NoYesHome Mortgage Name on Account Home Mortgage Account Number (last 4 digits only) Do you owe money on a line of credit?NoYesLine of credit Name on Account Line of credit Account Number (last 4 digits only) Do you owe money on a credit card?NoYesCredit Card Name on Account Credit Card Account Number (last 4 digits only) Are you a guarantor on any third party debts?NoYesThird party debt Name on Account Third party debt Account Number (last 4 digits only) Do you have any other debts?NoYesOther debt Name on Account Other debt Account Number (last 4 digits only) Have you “earmarked” any insurance policies to pay off any of the liabilities that were listed?YesNoExplain your earmarking intentions.Special CircumstancesAre you financially responsible for any dependents, other than your children?NoYesDependent(s) information.Do you have financial responsibility for a special needs family member?NoYesProvide further information. Estate PlanningAll questions apply for you and/or your spouse.Do you currently have Financial and Health Care Powers of Attorney document in place?NoYesName of Fiduciary or Agent Date of Power of Attorney document MM slash DD slash YYYY Do you (or your spouse) have another Power of Attorney document?NoYesDate and Name of Fiduciary or Agent for additional Power of Attorney document(s).Do you currently have a Living Will, Health Care Declaration, or Advanced Directive in place?NoYesName of Fiduciary or Agent on Living Will, Health Care Declaration, or Advanced Directive Date of Living Will, Health Care Declaration, or Advanced Directive MM slash DD slash YYYY Do you (or your spouse) have another Living Will, Health Care Declaration, or Advanced Directive?NoYesDate and Name of Fiduciary or Agent for additional Living Will, Health Care Declaration, or Advanced Directive(s).Do you currently have a Last Will & Testament in place?NoYesName of Fiduciary or Agent on Last Will & Testament Date of Last Will & Testament MM slash DD slash YYYY Do you (or your spouse) have another Last Will & Testament?NoYesDate and Name of Fiduciary or Agent for additional Last Will & Testament(s).Do you currently have any Trust documents in place?NoYesName(s) of Trustees Date of Trust documents MM slash DD slash YYYY Do you (or your spouse) have any other Trust document(s)?NoYesDate and Name(s) of Trustees for additional Trust document(s).Three groups can benefit from your estate: 1) family/heirs, 2) ministries/charities, and/or 3) the government (in the form of taxes, at death). As an estimated percentage, how much does your current estate plan leave to each of these groups?1) Family/Heirs I don't know. 2) Ministries/Charities I don't know. 3) The Government I don't know. As an estimated percentage, how much would you like your estate plan leave to each of these groups?1) Family/Heirs 2) Ministries/Charities 3) The Government We Can Help!If the percentages in your current plan do not match the percentages that you wish to leave, we can help you put a plan in place to be sure your finances are distributed as you want.Special InstructionsIn the event of your death, do you or your spouse have special requests/instructions regarding… You may leave this blank for now and submit it to Ambassador Advisors at a later time if you wish.Pet care?NoYesI’d like to think about this, and add it at a later timePet care special instructions.Organ donation?NoYesI’d like to think about this, and add it at a later timeOrgan donation special instructions.Obituary?NoYesI’d like to think about this, and add it at a later timeObituary special instructions.Write your own obituary (optional).Funeral service/Burial?NoYesI’d like to think about this, and add it at a later timeFuneral service preferred minister Funeral service pallbearers Funeral service eulogy Funeral service special songs, music, poetry, etc. Funeral service: "Donations to _________ in lieu of flowers" Funeral service other requests.Tombstone engraving?NoYesI’d like to think about this, and add it at a later timeTombstone engraving special instructions. Special Instructions (continued)You may leave this blank for now and submit it to Ambassador Advisors at a later time if you wish.In the event of your incapacitation or death, do you have personal message(s) to family and/or friends?NoYesI’d like to think about this, and add it at a later timeFamily medical historyGeneral family historyCharities/ministries that I supportLearning experiences, values and traditions I wish to pass onMost important thing I’ve done in my lifeGoals/dreams that I hope my family will accomplishHow I hope to be rememberedOtherWe want to assure you that whenever information is collected and/or used, it is done with discretion. The safeguarding of client information is an issue we take seriously at Ambassador Advisors. To affirm our continuing commitment to the proper use of the information collected in this survey, we have set forth a complete Privacy Policy, which you may read in full, if desired. Click here to view our complete Privacy Policy.CommentsThis field is for validation purposes and should be left unchanged. Δ