Investment Assessment Questionnaire

INVESTMENT ASSESSMENT QUESTIONNAIRE

WHEREAS, Advisor Name: provides investment advisory and related services to clients under written engagement terms; and

WHEREAS, Client Name: seeks to engage Advisor and to provide information necessary to determine the suitability of investment recommendations; and

WHEREAS, the parties desire to establish the scope of the engagement, payment terms and to record the Client's investment profile and acknowledgements for suitability and compliance purposes.

Scope of Work

The Advisor shall provide investment assessment, suitability analysis, portfolio recommendations and ongoing monitoring as described below. Describe the services, deliverables and any limitations.

Payment Terms

Fees for the services described will be charged as set forth below. Client agrees to pay the Advisor in accordance with these terms.

Term and Termination

This engagement commences on Start Date and continues until End Date unless earlier terminated in accordance with this section.

Start Date:     End Date:

Either party may terminate this engagement for convenience upon delivery of the notice period above. Termination for cause may be immediate for material breach, fraud, gross negligence, or other conduct rendering performance unlawful or impossible. Upon termination, Advisor shall invoice for work performed through the effective date of termination; Client shall pay all undisputed amounts within thirty (30) days.

Confidentiality

Each party shall maintain in strict confidence all non-public information disclosed by the other party in connection with this engagement ("Confidential Information"). Confidential Information shall not include information that is or becomes publicly available through no breach by the receiving party, or is rightfully obtained from a third party. The receiving party shall use Confidential Information solely for the purposes of performing obligations under this Agreement and shall restrict access to those employees and agents who have a need to know.

Governing Law

This Agreement, including all matters of construction, validity and performance, shall be governed by and construed in accordance with the laws of State: without regard to conflict of laws principles.

Entire Agreement

This document, together with any schedules or addenda signed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, proposals, and agreements, whether written or oral. No amendment shall be effective unless in writing and signed by both parties.

Investor Profile and Questionnaire

Date of Birth:     Tax ID / SSN (last 4 digits preferred):

Individual    Trust    Corporation    Partnership    Other:

Investment Objectives (select all that apply)

Preservation of capital    Income generation    Growth & income    Growth    Speculation

Risk Tolerance

Please indicate the single selection that best represents your overall risk tolerance (check one).

Conservative (preserve capital, minimal volatility)    Moderately Conservative    Moderate    Moderately Aggressive    Aggressive (high volatility acceptable)

Investment Experience

No prior investment experience    Less than 1 year    1–3 years    3–5 years    More than 5 years

Current Asset Allocation (percentages)

Equities (stocks):    Fixed Income (bonds):    Cash / Short-term:    Alternatives:

Acknowledgements and Certifications

By initialing and signing below, the Client certifies that the information provided in this questionnaire is true, complete and accurate to the best of the Client's knowledge. The Client acknowledges that investment recommendations are based upon the information contained herein and that providing inaccurate or incomplete information may result in unsuitable recommendations.

Client acknowledges that Advisor has disclosed any material conflicts of interest, and that Advisor's role and any fees or compensation arrangements have been described to Client. Client understands that past performance is not indicative of future results and that no guarantees are made with respect to investment performance.

I acknowledge and certify that the information provided is accurate and that I have read and understand the terms of engagement and confidentiality provisions above.

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