Investment Policy Statement (IPS) Questionnaire

This questionnaire is for our Access level service.

- Step 1 of 4

Preliminary Questions

Your Advisor *

Please select your advisor

How did you hear about us? *

Other

Account Owner (or minor account owner for UTMA)

Name *

First

Last

Social Security Number *

You must provide your Social Security Number (SSN) in order for ShariaPortfolio to process your account request. For more information on why this is required, please visit https://www.sec.gov/fast-answers/answersbd-persinfohtm.html

Date of Birth *

Home Address *

Address Line 1

City

State

Zip Code

Email *

Phone *

Occupation *

Type of Business (Source of Income) *

Employer Name *

Employer Address *

Address Line 1

City

State

Zip Code

U.S. Citizen *

Permanent Resident *

Country of Citizenship

Marital Status *

Single
Married
Divorced
Widowed

Spouse Name

Spouse Profession

Spouse Birthday

Joint Account Owner (if applicable)

Are you filing a joint account? *

Name

First

Last

Relationship

Social Security Number

Date of Birth

Home Address

Address Line 1

City

State

Zip Code

Phone

Occupation

Type of Business (Source of Income)

Employer Name

Employer Address

Address Line 1

City

State

Zip Code

U.S. Citizen

Permanent Resident

Country of Citizenship

Children

Do you have children? *

How many children do you have?

Child Name (1)

First

Last

Child Gender (1)

Male
Female

Child SSN (1)

Child Date of Birth (1)

Child Name (2)

First

Last

Child Gender (2)

Male
Female

Child SSN (2)

Child Date of Birth (2)

Child Name (3)

First

Last

Child Gender (3)

Male
Female

Child SSN (3)

Child Date of Birth (3)

Child Name (4)

First

Last

Child Gender (4)

Male
Female

Child SSN (4)

Child Date of Birth (4)

Child Name (5)

First

Last

Child Gender (5)

Male
Female

Child SSN (5)

Child Date of Birth (5)

Child Name (6)

First

Last

Child Gender (6)

Male
Female

Child SSN (6)

Child Date of Birth (6)

Beneficiaries

Beneficiary 1

First

Last

SSN / DOB

First

Last

Beneficiary 1 Address

Address Line 1

City

State

Zip Code

Type

Primary
Contingent

Beneficiary 1 Share %

Beneficiary 2

First

Last

Beneficiary 2 SSN / DOB

First

Last

Beneficiary 2 Address

Address Line 1

City

State

Zip Code

Type

Primary
Contingent

Beneficiary 2 Share %

Beneficiary 3

First

Last

Beneficiary 3 SSN / DOB

First

Last

Beneficiary 3 Address

Address Line 1

City

State

Zip Code

Type

Primary
Contingent

Beneficiary 3 Share %

Beneficiary 4

First

Last

Beneficiary 4 SSN / DOB

First

Last

Beneficiary 4 Address

Address Line 1

City

State

Zip Code

Type

Primary
Contingent

Beneficiary 4 Share %

Objectives & Risk Profile

Income / Debt Information

First

Last

Net Worth / Cash Information

First

Last

Major Expenses

Investment Experience *

None
Limited
Good
Extensive

Investment Style *

Conservative
Moderate
Aggressive

Primary Goals (please check all that apply) *

Retirement
Reduce Taxes
College Funding
Return on Assets
Other

Other

On a scale of 1 to 5 (1 being the most important) please rate the following in order of importance:

	1	2	3	4	5
Reduce Taxes	Reduce Taxes 1	Reduce Taxes 2	Reduce Taxes 3	Reduce Taxes 4	Reduce Taxes 5
Capital Preservation	Capital Preservation 1	Capital Preservation 2	Capital Preservation 3	Capital Preservation 4	Capital Preservation 5
Income Generation	Income Generation 1	Income Generation 2	Income Generation 3	Income Generation 4	Income Generation 5
Estate Planning	Estate Planning 1	Estate Planning 2	Estate Planning 3	Estate Planning 4	Estate Planning 5
Capital Appreciation	Capital Appreciation 1	Capital Appreciation 2	Capital Appreciation 3	Capital Appreciation 4	Capital Appreciation 5

Current Investments

CPA or Other Interested Party

This is any individual the client wishes us to discuss the account with.

CPA / Interested Party Name

CPA / Interested Party Firm Name / Phone

First

Last

CPA / Interested Party Email

Investment Preferences

Your advisor can help you select your account types and strategies based on your goals, risk tolerance and personal preference or leave blank if unsure.

Account Type(s) / Strategy

First

Last

Account Type(s) / Strategy

First

Last

Account Type(s) / Strategy

First

Last

Account Type(s) / Strategy

First

Last

Notes

Method of Deposit *

Check made payable to TD Ameritrade
Transfer from another institution
Set-up ACH transfer from a bank account

Preferred Method of Communication *

Email
Phone Call
Text Message
U.S. Mail

Preferred Date/Time of Communication *

Mornings
Evenings
Weekends

Specific Date/Time Preferred

First

Last

Account Owner *

First

Last

Account Owner Signature *

Joint Account Owner

First

Last

Joint Account Owner Signature

Risk Assessment Questionnaire

Different investors have different risk tolerances. Much of these differences stem from the time horizon. With this in mind, an investor with a short investment time horizon is less able to withstand losses. The remaining differences are attributed to an investors tolerance for risk. The following questions will allow us to better determine your individual Risk Profile, such as overall ability (time horizon) and willingness (risk tolerance). At the end of the questionnaire, your total score will suggest which of the five Risk Profiles suit you best.

Time Horizon

1. When do you expect to begin withdrawing from this portfolio? *

Less than 1 year (0)
1 to 2 years (1)
3 to 4 years (3)
5 to 7 years (7)
8 to 10 years (9)
11 years or more (11)

2. Once you begin withdrawing money from your investment, over how long a period do you anticipate the withdrawals to continue? *

I plan to take a lump sum distribution (0)
1 to 2 years (2)
3 to 4 years (4)
5 to 8 years (5)
9 to 10 years (6)
11 years or more (8)

Risk Tolerance

3. Inflation can greatly erode the return on your investments, especially over time. For example, in a typical year with a 3.5% inflation rate, a 6% return before inflation would have a real return of only 2.5% (6% – 3.5% = 2.5%). Which of the follow ing portfolios is mo st consistent with your thoughts regarding investing and inflation? *

Portfolio 1 will most likely exceed long-term inflation by a significant margin and has a high degree of volatility. (12)
Portfolio 2 will most likely exceed long-term inflation by a moderate margin and has a moderate to high degree of volatility. (8)
Portfolio 3 will most likely exceed long-term inflation by a small margin and has a small to moderate degree of volatility. (4)
Portfolio 4 will most likely match inflation and has low degree of risk volatility. (0)

4. Portfolios with the highest average returns also tend to have the highest chance of short-term losses. The table below provides the average dollar return of five hypothetical investments of $100,000 and the possibility of lower value (ending value of less than $100,000) or higher value (ending value of more than $100,000) over a one - year holding period. Please select the portfolio with which you are most comfortable investing. *

Portfolio A: Expect Value: $106,400 - Chance of higher value after one year: 85% - Chance of lower Value after one year: 15% (0)
Portfolio B: Expect Value: $107,700 - Chance of higher value after one year: 82% - Chance of lower Value after one year: 18% (3)
Portfolio A: Expect Value: $108,800 - Chance of higher value after one year: 78% - Chance of lower Value after one year: 22% (6)
Portfolio A: Expect Value: $109,700 - Chance of higher value after one year: 74% - Chance of lower Value after one year: 26% (9)
Portfolio A: Expect Value: $110,400 - Chance of higher value after one year: 72% - Chance of lower Value after one year: 28% (12)

5. Investing involves a trade-off between risk and return. Historically, investments with higher returns have been associated with greater risk and chance for loss. Alternatively, cautious investments that have had a lower chance for loss, also have yielded lower returns. Considering the above, which of the following statements best describe your thoughts regarding risk? *

I am most concerned with risk. I am willing to accept the lower returns in order to limit my chance of loss (0)
I am willing to bear some risk and chance for loss in an effort to achieve slightly higher returns, but prefer a significant portion of my portfolio to be invested cautiously in assets (3)
I am willing to accept moderate risk and chance of loss in order to achieve higher returns. Limiting risk and maximizing returns are of equal importance to me (6)
I wish to achieve high returns on my investments. I am willing to accept high rish and chance of loss. (9)
I am primarily concerned with maximizing the returns of my investments and am willing to accept large and sometimes dramatic short-term fluctuations in the value of this portfolio. (12)

6. Sometimes investment losses are permanent, sometimes they are prolonged, and sometimes they are short-term followed by market recoveries. How might you respond when you experience investment losses? *

Even if my investments suffered a significant decline over several years, I would continue to follow my long-term investment strategy and not adjust my portfolio. (12)
I can endure significant declines in the value of my investments and would wait at least one year before adjusting my portfolio. (8)
Although declines in investment value make me uncomfortable, I would wait one - two quarters before adjusting my portfolio. (4)
I would sell my investments immediately or change to a more conservative portfolio if they suffered substantial declines. (0)

7. The options below describe five sample portfolios and their potential* portfolio gain and loss outcomes over a short time horizon (i.e. 1 year). Note: Investments carrying a higher risk come with the potential of achieving more gains, but also a higher possibility of incurring considerable losses. *Potential portfolio gain/loss values are for illustrative purposes. Clients should not rely on such figures to be indicative of their portfolio gain/loss with the bank. Which of the following sample portfolios would be most attractive to you? *

Portfolio A: Potential Gain: 9% - Potential Loss: 3%
Portfolio B: Potential Gain: 12% - Potential Loss: 10%
Portfolio C: Potential Gain: 25% - Potential Loss: 15%
Portfolio D: Potential Gain: 31% - Potential Loss: 20%
Portfolio E: Potential Gain: 40% - Potential Loss: 27%

ShariaPortfolio Inc. is registered as an investment advisor with the United States Securities & Exchange Commission and "Notice Filed" with State Regulatory Agencies that have limited regulatory jurisdiction over our advisory business practices. All information contained herein is for informational purposes only and does not constitute a solicitation or offer of investment advisory services except where ShariaPortfolio, Inc. is properly "Notice Filed" to do so. No new accounts will be accepted unless and until all local regulations are satisfied.

If you are interested in our services, please contact us and request a copy of our Disclosure Brochure (Part 2A of Form ADV: Firm Brochure) which provides detailed information about ShariaPortfolio, Inc. and any inherent risks that may be associated with our services.

View our Form CRS

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Investment Policy Statement (IPS) Questionnaire

This questionnaire is for our Access level service.

Preliminary Questions

Account Owner (or minor account owner for UTMA)

Joint Account Owner (if applicable)

Children

Beneficiaries

Objectives & Risk Profile

CPA or Other Interested Party

Investment Preferences

Risk Assessment Questionnaire

Time Horizon

Risk Tolerance

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ShariaPortfolio does not assume responsibility
for content of the site that this link is being directed to.