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Retirement Goal CheckupClient Questionnaire

Together with your Financial Advisor, explore what inspires you to embrace this new phase in your life with passion and excitement. To get started:

• Imagine you have already stopped working. Picture yourself at a party and another guest asks you what you do. How would you like to reply?

• Who are your retirement role models (parents, grandparents)? Do you want to follow their example?

• What will you be wearing in retirement? A swimsuit? A business suit?

When we understand where you are now and where you hope to be in the future, we can help you focus on your current spending patterns and the goals you’ve set for your retirement.

This retirement checkup is just one of several fi nancial planning services at UBS. If you’d like a more extensive review of your complete fi nancial plan, please ask your Financial Advisor.

What is my vision of retirement?

Will my plan for retirement help me get there?

Is my plan for retirement still on track?

The better we understand your vision for retirement, the better we can help you address your fi nancial needs.

2

1 Relationship can include child, grandchild, other dependent, benefi ciary/donee, charity, trust (e.g., Irrevocable Life Insurance Trust.)

Important Information about our fi nancial planning services

We off er both investment advisory and brokerage services, each of which is separate and distinct, diff ers in material ways and is governed by diff erent laws and separate contracts. Financial planning is an investment advisory service. This service terminates when the plan is delivered to the client. Note that fi nancial planning does not alter or modify in any way the nature of a client’s UBS accounts, their rights and our obligations relating to these accounts or the terms and conditions of any UBS account agreement in eff ect during or a er the fi nancial planning service. Clients are not required to establish accounts, purchase products or otherwise transact business with us to implement any of suggestions made in the fi nancial plan. Should a client decide to implement their fi nancial plan with us, we will act as either a broker-dealer or an investment adviser, depending on the service selected. For more information see www.ubs.com/workingwithus.com.

Neither UBS Financial Services nor its Financial Advisors provide tax or legal advice. Clients should be advised to contact their personal tax and/or legal advisors regarding their individual situations.

Children, Grandchildren and Other Dependents

Name Male Female

Date of birth/age Relationship1

Name Male Female

Date of birth/age Relationship

Name Male Female

Date of birth/age Relationship

Client Spouse

Name

Date of birth

Employment Retired Employed Retired Employed status Homemaker Business owner Homemaker Business owner Not currently employed Not currently employed

Employment income $ $

State of residence

Personal Information and Financial Goals

Financial Goals

Retirement Age

The ideal age is the desired retirement age. The acceptable age is the latest age that you may be willing to retire.

Client Spouse

Ideal Retirement Age

Acceptable Retirement Age

Willingness to retire later (if necessary) to attain goals?

Very willing Somewhat willing Slightly willing

Very willing Somewhat willing Slightly willing

Personal Information

3

High Low

Needs Wants Wishes

10 9 8 7 6 5 4 3 2 1

Other Retirement Goals

Description

Start Amount

HowO en

How Many Times

ImportanceHigh Low10 – 1Year

Or atRetirement Ideal Acceptable

Risk Tolerance and Investment PreferencesThese questions are designed to help develop an asset allocation strategy that addresses specifi c fi nancial goals. Please review and answer the following questions.

1. Primary objectiveOverall objective for this plan is to:

Produce current income

Achieve capital appreciation (emphasis on growth of capital, not income) Produce a combination of income and capital appreciation

2. Investment timeframeThe length of time intended to remain invested can play a signifi cant role in designing an appropriate investment strategy. Generally, the longer the investment timeframe, the more risk that can be taken to potentially achieve greater returns (assuming additional risk).

When will the majority of these funds be needed?

Less than three years

Three to six years (an average market cycle)

Seven to 10 years

Longer than 10 years (several market cycles)

Retirement Expense AmountThe ideal amount is the desired amount. The acceptable amount is the minimum estimated amount needed to spend on this goal.

Ideal Acceptable

When retirement begins whether single or marriedEnter planned expenditures of basic expenses during retirement in a er-tax dollars. $ $

Importance of this Goal High – Low

10 – 1

4

Risk tolerance and investment preferences continued

3. Risk/return objectivesMany investors have expectations of earning the high returns of a long-term investment, but feel compelled to liquidate prematurely because of their discomfort with short-term volatility. Identifying acceptable volatility is central to determining an appropriate investment strategy.

Which of the following statements best characterize risk/return objectives?

Interested in maintaining invested capital and not prepared to accept higher fl uctuations in the value of assets

Prefer to sustain only moderate fl uctuations in the value of assets to achieve moderate returns

In order to achieve a higher return, prepared to accept higher fl uctuations in the value of assets

4. Investment characteristicsWhich one of the following best characterizes tolerance for risk? Please check one of the following:

Low risk Some risk Moderate risk Moderately high risk High risk

5. Short-term cash needIs there a need for cash in the short term?

Yes No

6. Portion of total investable assets in this planWhat portion of total investable assets is refl ected in this plan?

Less than 20% 20% to 40% 41% to 60% 61% to 80% More than 80%

7. To what extent should tax-free municipal securities be taken into consideration? Not at all Minimally Somewhat Signifi cantly Fully

8. Please select which product types should be considered in an asset allocation recommendation. International equity Emerging markets International fi xed income High yield

REITs Alternative strategies Broad commodities

(Note: If alternative strategies is selected in question 8, please answer questions 9 – 10.)

9. Please indicate willingness to invest with professional money managers who, from time-to-time, may employ the types of investment strategies described in question 10?

Not comfortable Fairly comfortable Very comfortable

10. Is there some familiarity with the following investments or strategies and interest in investing in them again?

Private investment partnerships Hedge funds or managed futures Private equity or venture capital

Put and/or call options Futures/commodity contracts Short positions

5

Retirement Income Sources

Client Spouse

Eligible for Social Security Benefi ts Yes No Yes No

Other Retirement Income

(Include pension, real estate, trust and/or part-time employment income, do not include investment income)

Recipient Description When Will Income Start?

When Will Income End?

Annual Income Survivor Benefi t (if applicable)

Infl ation (if applicable)

$ %

$ %

$ %

$ %

Notes:

Investment Assets

Assets Held at Othe r Financial InstitutionsTo include assets that are held outside the fi rm [e.g., 401(k) assets held with an employer], please indicate their account values and where they are held in the spaces provided below. Note: Please provide copies of the most recent account statements or attach them to this profi le. The account statement should be dated within the last 60 days.

Account 1 Account 2 Account 3

Owner (client, spouse, joint)

Name of fi rm/account

Total current value $ $ $

Annual additions $ $ $

Stocks $ $ $

Bonds $ $ $

Cash $ $ $

Other $ $ $

Are these assets in an IRA or qualifi ed plan? Yes No Yes No Yes No

Annual contribution $ $ $

Extra Savings

Can more be saved to fund goals? Yes No

If yes, enter the maximum extra amount for each year in addition to the amounts entered with assets on the prior page. $

Willingness to save more? Very willing Somewhat willing Slightly willing

Resources

UBS Financial Services Inc.www.ubs.com/fi nancialservicesinc081006-2272

UBS Financial Services Inc. is a subsidiary of UBS AG.

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