Fact Finder - Capital A Wealth Management

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About
Our Process
Events
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Contact

Fact Finding

Step 1 of 9

11%

Basic Information
Your Name
First Last
Date of Birth
Spouse's Name
First Last
Spouse's Date of Birth
Residency Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address different from Residency?
- Yes
- No
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Fax
Email
How did you hear about Capital A Investments?
Occupation
Your job title
Employer (last, if retired)
# of years
Retirement Date
Spouse's job title
Employer (last, if retired)
# of years
Retirement Date

Family Assets
Personal
Primary Residence
Owner
Purpose
Current Value
Vacation home/second residence
Owner
Purpose
Current Value
Automobile(s)
Owner
Purpose
Current Value
Other Personal Assets
Owner
Purpose
Current Value
Other Personal Assets
Owner
Purpose
Current Value
Total Personal Assets
Total Personal Assets

Liquid And Investment
Cash
Owner
Purpose
Current Value
Fixed
Bond and Bond Mutual Funds
Owner
Purpose
Current Value
Bond and Bond Mutual Funds
Owner
Purpose
Current Value
Equity
Stocks and stock mutual funds
Owner
Purpose
Current Value
Stocks and stock mutual funds
Owner
Purpose
Current Value
Other investment assets
Owner
Purpose
Current Value
Total Liquid And Investment Assets
Total Liquid and Investment Assets

Retirement
IRA
Owner
Purpose
Current Value
IRA
Owner
Purpose
Current Value
Qualified retirement plan (e.g., 401(K))
Owner
Purpose
Current Value
Qualified retirement plan (e.g., 401(K))
Owner
Purpose
Current Value
Annuities
Owner
Purpose
Current Value
Other retirement assets
Owner
Purpose
Current Value
Total Retirement Assets
Total Retirement Assets
Total Assets
TOTAL ASSETS

Family Liabilities
Mortgage on first residence
Debtor
Current balance
Original balance
Origination date
Mortgage on second residence
Debtor
Current balance
Original balance
Origination date
Charge accounts and credit cards
Debtor
Current balance
Original balance
Origination date
Other liabilities
Debtor
Current balance
Original balance
Origination date
Total Liabilities
TOTAL LIABILITIES

Family Income
Annual Income
Employment (wages, salaries, bonuses)
Primary
Secondary
Self-employment/business income
Primary
Secondary
Social Security benefits
Primary
Secondary
Other government benefits
Primary
Secondary
Taxable investment income
Primary
Secondary
Nontaxable investment income
Primary
Secondary
Pensions (if currently receiving)
Primary
Secondary
Other income - taxable
Primary
Secondary
Other income - nontaxable
Primary
Secondary
Total Annual Income
Primary
Secondary
Combined Total Annual Income
TOTAL
Family Expenses
Fixed
Variable
TOTAL

General
Are you anticipating any major lifestyle changes?(i.e., marriage, divorce, retirement, moving, etc.)
- Yes
- No
- Uncertain
If so, what changes are you expecting?
Are you comfortable with your current cash flow?
- Yes
- No
- Uncertain
Do you anticipate any significant changes in your cash flow?
- Yes
- No
- Uncertain
Do you anticipate any major expenditures in the near future?
- Yes
- No
- Uncertain
If so, what expenditures are you expecting?
Protection
Do you have any potential health problems?
- Yes
- No
- Uncertain
Do you have adequate medical coverage?
- Yes
- No
- Uncertain
Do you have adequate disability coverage?
- Yes
- No
- Uncertain
Do you have adequate personal liability coverage?
- Yes
- No
- Uncertain
Amount
Do you have enough life insurance?
- Yes
- No
- Uncertain
Do you have an emergency fund (money set aside in savings)?
- Yes
- No
- Uncertain
Estate Planning
Do you have updated/adequate wills?
- Yes
- No
- Uncertain
Have you established any trusts?
- Yes
- No
- Uncertain
Will you be receiving a significant inheritance?
- Yes
- No
- Uncertain
Have you adequately considered estate tax?
- Yes
- No
- Uncertain
Have you provided adequate estate liquidity for your heirs?
- Yes
- No
- Uncertain
Is proper titling a concern?
- Yes
- No
- Uncertain
Do you have long-term health care coverage?
- Yes
- No
- Uncertain
Concerns
Please list any concerns you may have:

Goals
What are your major objectives for your investments?
- Current and future income
- Preserving capital
- Building wealth for heirs
- Keeping ahead of inflation
- Increasing returns
INVESTMENT GOALS

(Rank from Low Priority (1) to High Priority (10))
Return should exceed inflation rate
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Principle should be safe
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Investments should be liquid (immediately accessible)
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Diversification is important
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
I want to reduce my taxable income
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
I want to build tax-free income
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
I am interested in long-term growth
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
I am interested in short-term profits
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10

Risk Profile
I expect to start drawing income from this investment:
- Not for at least 20 years
- In 10 to 20 years
- In 5 to 10 years
- Not now, but within 5 years
- Immediately
For this investment my goal is:
- To grow aggressively
- To grow with caution
- To avoid losing money
Assuming normal market conditions, what would you expect from this investment over time?
- To generally keep pace with the stock market
- To trail the stock market, but make a decent profit
- To have a high degree of stability, but only modest profits
Suppose the stock market performs unusually poorly over the next decade. Then what would you expect from this investment?
- I will be OK if I lose money
- To make a small gain
- To be little affected by what happens in the stock market
Which of these statements would best describe your attitude about the next three years’ performance of this investment?
- I’ll be OK if I lose money
- I want to at least break even
- I need at least a small profit
Which of these statements would best describe your attitude about the next three months’ performance of this investment?
- Who cares? One calendar quarter means absolutely nothing
- If I suffered a loss of greater that 10% I’d get concerned
- I can tolerate only small short-term losses
Email
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To schedule a time to discuss your financial future and the possible role of investments and insurance in your financial strategy, contact us at info@capitalainvestments.com or call us at 724.658.4211 today!

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Contact Us

Phone: 724.658.4211
Fax: 724.658.4418
Email Us!

Locations

8050 Rowan Road, Suite #602
Cranberry Township, PA 16066

312 N. Jefferson Street

New Castle, PA 16101

KIEFER FINANCIAL SERVICES powered by CAPITAL A WEALTH MANAGEMENT

6715 Tippecanoe Road, Building B
Canfield, OH 44406
Phone: 330.533.2174

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North Regional Chamber

Any media logos and/or trademarks contained herein are the property of their respective owners and no endorsement by those owners of Capital A Wealth Management is stated or implied.

Securities offered only by duly registered individuals through Madison Avenue Securities, LLC (MAS), member FINRA/SIPC. Investment advisory services offered only by duly registered individuals through Capital A Wealth Management, LLC (CAWM), a Registered Investment Adviser. Certain CAWM registered individuals may market investment advisory services under the marketing name Kiefer Financial Services (KFS). CAWM and KFS are not affiliated with MAS.

Investing involves risk, including the potential loss of principal. No investment strategy can guarantee a profit or protect against loss in periods of declining values. None of the information contained on this website shall constitute an offer to sell or solicit any offer to buy a security or any insurance product.

*Any references to protection benefits or steady and reliable income streams on this website refer only to fixed insurance products. They do not refer, in any way, to securities or investment advisory products. Annuity guarantees are backed by the financial strength and claims-paying ability of the issuing insurance company. Annuities are insurance products that may be subject to fees, surrender charges and holding periods which vary by insurance company. Annuities are not FDIC insured.

The information and opinions contained in any of the material requested from this website are provided by third parties and have been obtained from sources believed to be reliable, but accuracy and completeness cannot be guaranteed. They are given for informational purposes only and are not a solicitation to buy or sell any of the products mentioned. The information is not intended to be used as the sole basis for financial decisions, nor should it be construed as advice designed to meet the particular needs of an individual's situation.

The Better Business Bureau membership provides no guaranteed assurance or warranty of the character or competence of the member. BBB charges a fee for BBB Accreditation. You should make financial decisions on the basis of your own due diligence.

Council of Financial Educators (COFE) is a paid membership organization comprised of professionals of varying specialties. "COFE" is a 501(c)(3) non-profit organization whose focus is to provide financial education to individuals, businesses, and organizations through member professionals. The "COFE" logo and/or trademarks are property of their respective owners and no endorsement of Brandon Domenick or Capital A Wealth Management is stated or implied. 1987612 - 10/23

Fact Finding

Step 1 of 9

Basic Information

Occupation

Family Assets

Personal

Primary Residence

Vacation home/second residence

Automobile(s)

Total Personal Assets

Liquid And Investment

Cash

Fixed

Bond and Bond Mutual Funds

Bond and Bond Mutual Funds

Equity

Stocks and stock mutual funds

Stocks and stock mutual funds

Total Liquid And Investment Assets

Retirement

IRA

IRA

Qualified retirement plan (e.g., 401(K))

Qualified retirement plan (e.g., 401(K))

Annuities

Other retirement assets

Total Retirement Assets

Total Assets

Family Liabilities

Mortgage on first residence

Mortgage on second residence

Charge accounts and credit cards

Other liabilities

Total Liabilities

Family Income

Annual Income

Employment (wages, salaries, bonuses)

Self-employment/business income

Social Security benefits

Other government benefits

Taxable investment income

Nontaxable investment income

Pensions (if currently receiving)

Total Annual Income

Combined Total Annual Income

Family Expenses

General

Protection

Estate Planning

Concerns

Goals

INVESTMENT GOALS

(Rank from Low Priority (1) to High Priority (10))

Risk Profile