Professional Fiduciary Questionnaire

PROFESSIONAL FIDUCIARY QUESTIONNAIRE

GENERAL INFORMATION

Name of applicant:______Date:______

SSN:______

Residence address:______

______

Business address:______

______

Phone:______

Year business started:______

Please list all partners and/or corporate officers, if applicable:______

Please list any other division, subsidiary or affiliate, if applicable:______

______

If any revenue is generated from sources other than client fees, please detail their percentages of total revenue: ______

Please detail your current case load:______

______

Number of employees: ______

Please list your current staff and qualifications: ______

INTERNAL CONTROLS (FOR YOUR OFFICE)

Do you have a safe in the office? ______

Name and address of your C.P.A.: ______

______

______

Is an annual audit performed by your C.P.A.? ______

Name and address of your bank(s):

Bank: ______

Address: ______

______

Bank: ______

Address: ______

______

Who reconciles the bank accounts: ______

How often? ______

Is there a counter-signature requirement? ______

If so, by whom and at what limit is this implemented? ______

______

Name and address of your legal counsel: ______

______

Limits of insurance:

Professional liability insurance:

Amount: ______

Company: ______

Directors and Officers Liability Insurance:

Amount: ______

Company: ______

Fidelity bond:

Amount: ______

Company: ______

List any other insurance: ______

INTERNAL CONTROLS (FOR YOUR CLIENTS)

Do you have a safe that is used for client's property? ______

Name and address of C.P.A. used for your clients: ______

______

List bank(s) utilized for your clients accounts:

Bank: ______

Address: ______

______

Bank: ______

Address: ______

______

Bank: ______

Address: ______

______

Bank: ______

Address: ______

______

Who reconciles these bank accounts? ______

How often? ______

Is there a counter-signature requirement? ______

If so, by whom and at what limit is this implemented? ______

______

List three attorneys and their firms that have represented you as a fiduciary:

1. ______

2. ______

3. ______

How are cash receipts for your client's accounts handled? ______

How are cash disbursements from your client's accounts handled? ______

How is the reporting of insurance claims and insurance reimbursements handled?

______

How are the investments for clients accounts handled?

______

Who prepares and reviews the case accountings? ______

ADDITIONAL INFORMATION

Number of cases currently bonded: ______

What Surety company(ies) issued the bonds? ______

______

Has any company refused to issue or continue providing bonds for you? ______

If so, why? ______

Are you a member of a Professional Fiduciary Association? ______

If so, where? ______

Annual Income: ______

Value of Real Estate: ______Amount Owing:______

Value of Assets ______Liabilities: ______

GIVE TWO PERSONAL REFERENCES

Name: ______Name: ______Relationship: ______Relationship: ______

Occupation: ______Occupation: ______

Address: ______Address: ______

______

Please attach any of the following that is available:

-Company brochure

-Resume(s)

-Current company financial statement