Client Fact Finder

DATE

Date

CLIENT INFORMATION

Name*

First NameMiddle NameLast Name

Date of Birth

Date

Marital Status

Address

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Email

example@example.com

EMPLOYMENT

Employment Status

Employment Title

Company Name

Gross Annual Income

Average Bonus (if any)

Start Date

Date

Work Address

Work Phone

Past Employment Title

Past Employment Industry

Driver's License #

State

Issue Date

Date

Exp Date

Date

Is there a Co-Client (partner, spouse, etc.)?

YesNo

CO-CLIENT INFORMATION

Co-Client Name

First NameMiddle NameLast Name

Date of Birth

Date

Cell Phone Number

Area CodePhone Number

Email

example@example.com

EMPLOYMENT

Employment Status

Employment Title

Company Name

Gross Annual Income

Average Bonus (if any)

Employment Date

Date

Work Address

Work Phone

Past Employment Title

Past Employment Industry

Driver's License #

State

Issue Date

Date

Exp Date

Date

DEPENDENTS / BENEFICIARIES

Name

First NameMiddle NameLast Name

Relationship to Client

D.O.B.

Date

Name

First NameMiddle NameLast Name

Relationship to Client

D.O.B.

Date

Name

First NameMiddle NameLast Name

Relationship to Client

D.O.B.

Date

Name

First NameMiddle NameLast Name

Relationship to Client

D.O.B.

Date

What are your plans, if any, for additional children?

Do you expect to support parents, siblings or other relatives now or in the future?

FINANCIAL INFORMATION

Tax Bracket

Risk Tolerance

Will

YesNo

Date or Last Reviewed

Date

Trust

YesNo

Dated

Date

Attorney Name

Attorney Address

Attorney Phone Number

Title of Trust: Client

Date of Trust

Date

Title of Trust: Co-Client

Date of Trust

Date

Cash Accounts

Please submit Financial Statements for as many accounts as possible by following the instructions in the "Documents Checklist" link on the previous page; the submission should be done following the completion of this form.

Checking

Savings

CD's/Money Markets

Other Assets

Please include assets in Retirement Accounts here.

Bonds

Stocks

Mutual Funds

Annuities

IRAs

401(k)s

Pensions

529 Savings Plans

Other

Total Death Benefit (Life Insurance), Disability Insurance & Long-Term Care

Total Death Benefit: Client

Total Death Benefit: Co-Client

Life Insurance Death Benefit

Client

Co-Client

Short-Term Disability: Client

Short-Term Disability: Co-Client

Long-Term Disability: Client

Long-Term Disability: Co-Client

Long-Term Care: Client

Long-Term Care: Co-Client

Real Estate (Primary)

Date of Purchase (Primary)

Date

Owned by

Purchase Price

Market Value

Remaining Mortgage Amount

Monthly Payment

Term

Interest Rate

Interest Type

FixedVariable

Other Real Estate

Date of Purchase (Other)

Date

Owned by

Purchase Price

Market Value

Remaining Mortgage Amount

Monthly Payment

Term

Interest Rate

Interest Type

FixedVariable

Location/Description of Property

Other Liabilites

Student Loans, Car Loans, Credit Cards, etc.

Estimated Total Capital

Net Worth

Other Financial Information

Do you pay off your credit cards to $0 balances monthly?

YesNo

If no, is there a budgeting or income issue? Please explain:

Current Needs/Concerns/Reason for Visit:

Do you currently contribute to an employer retirement plan (i.e. 401k, etc.)?

YesNo

How do you determine your contribution amounts?

Do your contributions have an employer match? If so, what is the match?

At what age would the Client like to retire?

Latest age?

Latest age? - saved for data purposes

At what age would the Co-Client like to retire?

Latest age?

What order of Retirement do you prefer?

Both retire in the same yearEither can retire firstOnly Client can retire firstOnly Co-Client can retire first

How willing is the Client to retire later (if necessary) to attain your goals?

Not at AllSlightlySomewhatVery

How willing is the Co-Client to retire later (if necessary) to attain your goals?

Not at AllSlightlySomewhatVery

Which of our Services are you interested in?

How did you hear about us? (If someone referred you, please let us know who.)

Is there any additional financial information or concerns that you would like for us to know?

FINANCIAL ADVISOR USE

Summary/Action Decided

Why?

Purpose of Investment

Source of Funds to be used

Investment Time Frame

less than 3 yrs3-7 yrs7-10 yrs10+ yrs