Client Information Form – Comprehensive Financial

Basic info

First Name *

Middle Name

Last Name *

DOB

Social Security #

Contact info

Mobile #

Home #

Personal Email *

Work Email

Drivers license info

Driver's License Number

Expiration Date

Date issued

Issued State

Residence info

Do you rent or own a home?

I own a home.
I rent a home.

Address 1 *

Address 2

City *

State

Zipcode *

Country *

Marital/Partner Info

What is your current marital status? *

Married
Divorced
Single
Domestic Partner

Spouse/Partner Information

Spouse/Partner First Name

Spouse/Partner Middle Name

Spouse/Partner Last Name

Spouse/Partner DOB

Spouse/Partner Social Security #

Spouse/Partner Driver's License Number

Spouse/Partner Driver's License Expiration Date

Spouse/Partner Driver's License Issue Date

Spouse/Partner Driver's License State

Dependents

Do you have dependents?

How many dependents do you have?

Dependent #1

Dependent #1 Full Name

Dependent #1 DOB

Dependent #1 Social Security #

Dependent #2

Dependent #2 Full Name

Dependent #2 DOB

Dependent #2 Social Security #

Dependent #3

Dependent #3 Full Name

Dependent #3 DOB

Dependent #3 Social Security #

Dependent #4

Dependent #4 Full Name

Dependent #4 DOB

Dependent #4 Social Security #

Dependent #5

Dependent #5 Full Name

Dependent #5 DOB

Dependent #5 Social Security #

Does anyone have special needs?

If yes, please describe

Annual Income

Your annual income *

Spouse/partner annual income *

Social Security Income

Your social security

Spouse/partner social security

Total Life Insurance

Your total life insurance

Spouse/partner total life insurance

Bank Accounts

(Checking/Savings/CD/MM)

How many bank accounts do you have?

Bank Account #1

Account type

Checking
Savings
Other

Bank name

Owner of account

$ Total amount

Purpose

Monthly Expenses

Please estimate your current monthly expenses.

Mortgage(s)/Rent:

Electric/Gas:

Water:

Lawn Care:

Home/Cell Phone:

Cable:

Streaming Services:

Internet:

Credit Cards:

Food:

Dining Out/Entertainment:

Gas:

Car Payment(s):

Commuting:

Insurance:

Health Care:

Child Care:

Pet Care:

Continuing Education:

Prescriptions/RX:

Gifts:

Beauty Expenses:

Donations:

Other Expenses:

Total Monthly Expenses

Your monthly expenses comes out to

360.00

Total Monthly Take Home Pay

Gross monthly income:

My feelings, concerns, and goals

Please rate your level of concern

	High Concern	Moderate Concern	No Concern	Not Applicable
Ensuring I have enough money in retirement	Ensuring I have enough money in retirement High Concern	Ensuring I have enough money in retirement Moderate Concern	Ensuring I have enough money in retirement No Concern	Ensuring I have enough money in retirement Not Applicable
A review of my investment portfolio and savings strategies	A review of my investment portfolio and savings strategies High Concern	A review of my investment portfolio and savings strategies Moderate Concern	A review of my investment portfolio and savings strategies No Concern	A review of my investment portfolio and savings strategies Not Applicable
Providing education funds for children	Providing education funds for children High Concern	Providing education funds for children Moderate Concern	Providing education funds for children No Concern	Providing education funds for children Not Applicable
Saving for a large purchase	Saving for a large purchase High Concern	Saving for a large purchase Moderate Concern	Saving for a large purchase No Concern	Saving for a large purchase Not Applicable
Assuring an income when I'm sick or hurt and cannot go to work	Assuring an income when I'm sick or hurt and cannot go to work High Concern	Assuring an income when I'm sick or hurt and cannot go to work Moderate Concern	Assuring an income when I'm sick or hurt and cannot go to work No Concern	Assuring an income when I'm sick or hurt and cannot go to work Not Applicable
Providing funds for long-term care (nursing home) in the future	Providing funds for long-term care (nursing home) in the future High Concern	Providing funds for long-term care (nursing home) in the future Moderate Concern	Providing funds for long-term care (nursing home) in the future No Concern	Providing funds for long-term care (nursing home) in the future Not Applicable
Getting help with my overall insurance planning (e.g., Life, Disability, Long-Term Care, Health, Property, and Casualty)	Getting help with my overall insurance planning (e.g., Life, Disability, Long-Term Care, Health, Property, and Casualty) High Concern	Getting help with my overall insurance planning (e.g., Life, Disability, Long-Term Care, Health, Property, and Casualty) Moderate Concern	Getting help with my overall insurance planning (e.g., Life, Disability, Long-Term Care, Health, Property, and Casualty) No Concern	Getting help with my overall insurance planning (e.g., Life, Disability, Long-Term Care, Health, Property, and Casualty) Not Applicable
Managing my estate	Managing my estate High Concern	Managing my estate Moderate Concern	Managing my estate No Concern	Managing my estate Not Applicable
In the event of my death: Paying off my mortgage and other debts	In the event of my death: Paying off my mortgage and other debts High Concern	In the event of my death: Paying off my mortgage and other debts Moderate Concern	In the event of my death: Paying off my mortgage and other debts No Concern	In the event of my death: Paying off my mortgage and other debts Not Applicable
In the event of my death: Allowing my family to maintain their current lifestyle	In the event of my death: Allowing my family to maintain their current lifestyle High Concern	In the event of my death: Allowing my family to maintain their current lifestyle Moderate Concern	In the event of my death: Allowing my family to maintain their current lifestyle No Concern	In the event of my death: Allowing my family to maintain their current lifestyle Not Applicable

Which risk level do you prefer?

I prefer to take almost no financial risk at the expense of achieving higher long-term returns.
I want to avoid short-term losses to achieve somewhat higher returns.
I am willing to accept some short-term losses in order to achieve returns that outpace inflation over the long-term.
I am comfortable with taking above average risks to achieve higher returns.

Financial Planning Check-Up

Basic info

Contact info

Drivers license info

Residence info

Marital/Partner Info

Spouse/Partner Information

Dependents

Dependent #1

Dependent #2

Dependent #3

Dependent #4

Dependent #5

Your employment info

Spouse/partner employment info

Annual Income

Social Security Income

Total Life Insurance

Bank Accounts

Bank Account #1

Bank Account #2

Bank Account #3

Bank Account #4

Bank Account #5

Investment Funds

Investment Fund #1

Investment Fund #2

Investment Fund #3

Investment Fund #4

Investment Fund #5

Real Estate

Property #1

Property #2

Property #3

Property #4

Property #5

Monthly Expenses

Total Monthly Expenses

Total Monthly Take Home Pay

My feelings, concerns, and goals

Topics for Future Discussion

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