The purpose of this form is to help you in gathering the basic information about your current financial situation which we will need in order to make the best use of our time together. Without knowing everything one is doing financially, it is next to impossible to discuss options available because what may be right in one set of circumstances may be harmful in another. All information provided will be kept strictly confidential. Background Information Family Data Your Date of Birth Spouse Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Employment Data Additional/Ancillary Income Source Amount Source Amount Source Amount Source Amount Source Amount Source Amount Accumulation/Savings Type Assess General Savings, Education, Retirement, etc. (List each account separately, by ownership and amount) Checking Account Checking Account Savings Account Credit Union Credit Union Savings Bond (Type) Certificate of Deposit Certificate of Deposit Money Market Account Money Market Account IRA Keogh Plan Single Premium Deferred Vested Pension Vested Profit Sharing 401K Other Other Investment Paper Type Assets Stocks, Bonds, Mutual Funds, etc. (Current Market Values) Government Securities T-Bills, Notes, Bonds (list type) GNMA, CMO, etc. (list type) Corporate Bonds Municipal Bonds Stocks Mutual Funds Partnerships Other Insurance Protection Home/Renters Insurance Liability Insurance Disability Insurance Medical Insurance (list all) Life Insurance (list all) Real Estate Assets Property Primary Residence 2nd Home 3rd Home Land Land Land Other Mortgages/Equity Lines of Credit Primary Residence Equity Line of Credit 2nd Home Equity Line of Credit 3rd Home Equity Line of Credit Additional Information 1. Do you have a safety deposit box? YesNo 2. Do you have valid, executed wills? YesNo Firm and/or name of your Attorney Firm and/or name of your Accountant Firms and/or names of past financial planners How did you hear about us? Where do you feel we can most help you? What 2 things would you most like to achieve in life? Please upload copies of applicable items below: Paycheck Stubs - most recent 2(Required) Statements on all Investments / Securities Please upload copies of applicable items below: Bank Statements – most recent 2 months(Required) Credit Card Statements - most recent 2 months Tax Return – most recent 2 years(Required) Please upload copies of applicable items below: Life Insurance Policies Car Insurance Policy Declaration Current Allowances (Request from HR):(Required) Save and Continue Later
