Step 1 of 9 11% Please complete this form for your 1st appointmentHow did you hear about us? You, and if married, your spouseClient Name* First Last Age*Social Security NumberDate of birth* Date Format: MM slash DD slash YYYY Email Phone*Profession*Married*YesNoSpouse Name First Last Spouse AgeSpouse SSNSpouse Date of Birth Date Format: MM slash DD slash YYYY Spouse Email Spouse PhoneSpouse ProfessionDate of Marriage Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry Your children, if any, or other potential beneficiariesLegal NameChild's Parent (Husband, Wife, Both)Date of BirthAgeIf child is married, Spouse's NameIf child has children, how many? Do you have any of the followingWill*YesNoPower of Attorney - Health*YesNoPower of Attorney - Financial*YesNoLiving Will*YesNoLong Term Care Insurance*YesNo(Nursing home, Home Health, Assisted Living)Umbrella Liability Insurance*YesNoAverage Monthly Expenses?*Does your monthly income cover your expenses?*YesNoDo you expect any major changes in your income?*YesNoAre you anticipating any major life style changes?*YesNoDo you expect to make any large purchases within three years?*YesNoFinancial Goals (Optional) Client IncomeClient Wages*Client Social SecurityClient Pension*Client Interest Income*Client Annuity Payments*Tax Bracket %Client Total IncomeSpouse IncomeSpouse WagesSpouse Social SecuritySpouse PensionSpouse Interest IncomeSpouse Annuity PaymentsSpouse Tax Bracket %Spouse Total Income Real EstateHome Value*Other Real EstateInvestment PropertyYesNoSecond HomeYesNoDebtDebt ListDebt NameAmount OwedPayoff Date Annuities & Life InsuranceCompany Name & Investment TypeOwner's InitialsIRA or 401k (Yes or No)Fixed or Variable (F or V)Interest Rate %Cash Value $Death Benefit $ Assets Including:Company Name & Investment TypeOwner's InitialsIRA or 401k (Yes or No)Interest Rate %Current Value $Original Value $Purchase Date Bank Accts, CDs, Money Markets, Brokerage Accts, Stocks, Bonds, Others Other AdvisorsNameClassificationFirm NameYears Affiliated Classifications: (1) Accountant (2) Attorney (3) Financial Advisor (4) Insurance Agent (5) Stock BrockerAdvisors Notes