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Please mail completed
form to our Orangeville Branch at:

Hogenhout & Associates
76 Broadway
Orangeville, Ontario
L9W 1J9

OR

fax to: (519) 942-1845

Thank you for your interest.

Hogenhout and Associates /
Dundee Private Investors Inc. Questionnaire

 

General Information
Client
Street
City
 Province
   
 
Person 1
Person 2
Name
Employer
Occupation
Date of Birth
Phone number
  Home
  Work
  Cell
E-mail
  Home
  Work
       
Children
Name  
Date of Birth  
Name  
Date of Birth  
Name  
Date of Birth  
Name  
Date of Birth  
Name  
Date of Birth  
Name  
Date of Birth  
 Statement of Net Worth
 
Person 1
Person 2
Name
Assets
Savings Accounts
Chequing Accounts
Investments
RRSPs
RRIFs
Employment Pension Plan
RESPs
In-Trust Accounts
Life Insurance Policies (Cash Surrender)
Real Estate - Home
Real Estate - Rentals
Vehicle
Business Interests
Other
Other
ASSETS - TOTAL
 
Liabilities
Demand Load
   
(1)
(2)
Credit Cards
    
(1)
(2)
(3)
RRSPs
RESPs
Real Estate
    
Home (1)
Home (2)
Rental (1)
Rental (2)
Vehicles
Business Interests
Other
Other

LIABILITIES - TOTAL
NET WORTH

 Statement of Net Cash Flows
 
Person 1
Person 2
Name
INFLOWS
Employment
Commissions
Self-employment
Old Age Security
Canada Pension Plan
Investment Income
Rental Income
Support Payments
RRSP
RRIF
Pension
Other
Other
Other
INFLOWS - TOTAL
 
OUTFLOWS
Demand Load
   
(1)
(2)
Credit Cards
    
(1)
(2)
(3)
Investments
RRSPs
RESPs
Real Estate
    
Home (1)
Home (2)
Rental (1)
Rental (2)
Vehicles
    
Regular
Insurance
Loan
Lease
Business Interests
Home
    
Mortgage Interest
Property Taxes
Heat
Hydro
Cable
Water
Insurance
Telephone
Other
Other
Child Care
Child Support
Alimony
Life Insurance
Cell Phone
Memberships
Food
Clothing
Entertainment
Other
Other
Other
Other
Other
Other
   

OUTFLOWS - TOTAL
NET CASH FLOWS