Fill and Sign the General Market Survey Form

General Market Survey 1. Are you: [ ] Male [ ] Female 2. What is your age? [ ] 18-24 [ ] 35-44 [ ] 55-64 [ ] 25-34 [ ] 45-54 [ ] 65 or over 3. What is the highest level of formal education you have completed? (Please check only one.) [ ] Without Degree [ ] Attended High School [ ] Attended College [ ] Post-Graduate Study [ ] Graduated High School [ ] Graduated College [ ] Post-Graduate Degree 4. What is your marital status? [ ] Married [ ] Separated or Divorced [ ] Single, Never Married [ ] Widowed 5. How many children under the age of 18 live in your household? __________ 6. What is your total annual personal income? ( Include income from all sources— salary, bonuses, investment income, rents, royalties, etc. Please check only one.) [ ] Less than $30,000 [ ] $40,000 - $49,999 [ ] $60,000 - $74,999 [ ] $100,000 - $149,999 [ ] $250,000 - $499,999 [ ] $1 million or more [ ] $30,000 - $39,999 [ ] $50,000 - $59,999 [ ] $75,000 - $99,999 [ ] $150,000 - $249,999 [ ] $500,000 - $999,999 7. In which state and ZIP code area is your main residence? State: _____________ ZIP code: _____________ 8. What is your total annual household income? (Include income for all family members and include all sources -- salary, bonuses, investment income, rents, royalties, etc. Please check only one.) [ ] Less than $30,000 [ ] $40,000 - $49,999 [ ] $60,000 - $74,999 [ ] $100,000 - $149,999 [ ] $250,000 - $499,999 [ ] $1 million or more [ ] $30,000 - $39,999 [ ] $50,000 - $59,999 [ ] $75,000 - $99,999 [ ] $150,000 - $249,999 [ ] $500,000 - $999,999 9. Do you own a home, condominium or co-op as your primary residence? [ ] Yes [ ] No If “Yes,” what is the present market value of your primary residence? [ ] Under $100,000 [ ] $100,000 - $199,999 [ ] $200,000 - $299,999 [ ] $400,000 - $499,999 [ ] $600,000 - 699,999 [ ] $300,000 - 399,999 [ ] $500,000 – 599,999 [ ] $700,000 – 799,000 If more, please estimate value: $ _______________________. 10. Do you own a second home, condominium or co-op? [ ] Yes [ ] No If “Yes,” what is the present market value of your primary residence? [ ] Under $100,000 [ ] $200,000 - $299,999 [ ] $400,000 - $499,999 [ ] $600,000 - $699,999 [ ] $100,000 - 199,999 [ ] $300,000 - 399,999 [ ] $500,000 – 599,999 [ ] $700,000 – 799,000 If more, please estimate value: $ _______________________. 11. What is the total net worth of yourself and all members of your household? Include the estimated market value of your business if you own one, all real estate, including primary residence, car, household possessions, bank accounts, stocks, bonds and other investments and assets. [ ] Less than $50,000 [ ] $50,000-$99,999 [ ] $100,000-$249,999 [ ] $250,000-$499,999 [ ] $500,000-$749,999 [ ] $750,000-$999,999 [ ] $750,000-$999,999 [ ] $1 million -$1.4 million [ ] $1.5 million -$1.9 million [ ] $2 million -$4.9 million [ ] $5 million -$9.9 million [ ] $10 million and over