Name: Age: Under 20 20-38 39-55 Over 55      Marital Status: Single Married Separated Divorced
City: Ottawa Nepean Gloucester Kanata Orleans Pembroke Toronto area Ottawa valley Ontario Canada Other Home Telephone: Email:

1) What would you consider to be your primary goal?      Retire comfortably Children's Education Enjoy travel and recreation Buy a home or cottage Pay off mortgage early Have my own business Save income tax Pay off debts Learn to manage money Retire Early Have a financial reserve Preserve my estate for beneficaries
2) What would you consider to be your secondary goal? Retire comfortably Children's Education Enjoy travel and recreation Buy a home or cottage Pay off mortgage early Have my own business Save income tax Pay off debts Learn to manage money Retire Early Have a financial reserve Preserve my estate for beneficaries
3) Who is your financial planner?                                      Myself A relative or close friend A person at my bank My stock broker Other
4) When was the last time you spoke to your financial planner about your goals? Within the last month Within the last six months Within the last year Within the last 5 years Never