Client Name*

First Name Last Name

Date of Birth*

Name of Account

Approximate Annual Income

Approximate Net Worth (Excluding Home)

Total Assets For Management

Source of Funds

Other Instructions

1. I plan to begin taking money from my investments in...*

2. As I withdraw money from these investments, I plan to spend it over a period of...*

3. When making a long-term investment, I plan to keep the money invested for...*

4. From September 2008 through November 2008, stocks lost more than 31% of their value. If I owned a stock investment that lost about 31% of its value in three months, I would...(If you owned stocks during this period, please select the answer that matches your actions at that time.)*

A. Sell all of the remaining investment B. Sell some of the remaining investment C. Hold on to the investment and sell nothing D. Buy more of the investment

5. Generally, I prefer an investment with little or no ups or downs in value, and I am willing to accept the lower returns these investments may make.*

6. When the market goes down, I tend to sell some of my riskier investments and put the money in safer investments.*

7. Based only on a brief conversation with a friend, coworker, or relative, I would invest in a mutual fund.*

8. From September 2008 through October 2008, bonds lost nearly 4% of their value. If I owned a bond investment that lost almost 4% of its value in two months, I would...(If you owned bonds during this period, please select the answer that matches your actions at that time.)*

A. Sell all of the remaining investment B. Sell some of the remaining investment C. Hold on to the investment and do nothing D. Buy more of the investment

9. The chart to the right shows the highest one-year loss and the highest one-year gain on three different hypothetical investments of $10,000.* Given the potential gain or loss in any one year, I would invest my money in...*

A. Investment A B. Investment B C. Investment C

10. My current and future income sources are...*

11. When it comes to investing in individual stocks or bonds (or stock or bond mutual funds), I would describe myself as...*

* The maximum gain or loss on an investment is impossible to predict. The ranges shown in the chart are hypothetical and are designed solely to gauge an investor's risk tolerance.

Intercontinental Wealth Advisors, LLC.