New Client Information

CONFIDENTIAL
New Client Information
Primary Owner Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Number *

Area Code Phone Number
Email *
example@example.com
Social Security Number *
Birth Date *

Month Day Year
Date
Drivers License Number *
Expiration Date *

Month Day Year
Date
Marital Status *
Number of dependents
Employer
Position/Title
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Phone Number

Area Code Phone Number
Spouse Information
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address (if Different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Number

Area Code Phone Number
Email
example@example.com
Social Security Number
Employer
Position/Title
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Phone Number

Area Code Phone Number
Drivers License Number
Expiration Date

Month Day Year
Date
Mother's Maiden Name
Primary Beneficiary (leave blank if spouse)
Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Social Security Number
Beneficiary Percentage
Birth Date

Month Day Year
Date
Contingent Beneficiary
Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Social Security Number
Beneficiary Percentage
Date of Birth

Month Day Year
Date
Additional Information
Do you have a will or trust?

Yes No
Name and date of trust:
Do you have any other investment accounts?

Yes No
Total amount of assets held in other investment accounts (attach or bring current statements to your appointment):
Do you have any insurance currently in force?

Life Insurance Long Term Care Insurance
Name of your attorney:
Name of your tax professional:
Investment Experience
Stocks
Bonds
Mutual Funds
Options
Annuities/Life Insurance
Financial Priorities (check all that apply)

Retirement Planning (build and review a plan, cash flow strategies, 401(k)s, Pensions, SIMPLEs, SEPs, ESOPs) Investment Management (goals, time horizon & risk tolerance assessment, asset allocation, customized portfolio design, ongoing monitoring, rebalancing, & maintenance) Tax Solutions (mitigation & minimization strategies, tax-efficient investing, tax loss harvesting, collaboration with your tax professional) Financial Planning (goals analysis & recommendation, business & education planning, cash flow & debt analysis, Personal CFO services) Life Transition Planning (Social Security analysis, Medicare & private healthcare planning) Legacy Planning (estate plan review & collaboration with your estate planning attorney) Advanced Strategies: Risk Mitigation (insurance: life, disability, long- term care, Key-man, Buy/Sell)
Investment Information
Investment Objective:
Primary source of funds to fund account:

Inheritance/Gift Salary/Wages
Investment time horizon:
Financial Information
Annual Income (all sources)
Net Worth (excluding residence)
Liquid Net Worth
Estimated value of all investments:
Tax Bracket
Anything else you would like to discuss?
Upload files (example: investment statements, tax returns)

Browse Files

Cancel of
All information is strictly confidential. Securities offered through Avantax Investment Services℠, Member FINRA,SIPC. Advisory services offered through Avantax Advisory Services℠, 400 S Jackson St. Jackson, MI 49201.
Should be Empty:

CONFIDENTIAL

New Client Information

Primary Owner Information

Spouse Information

Primary Beneficiary (leave blank if spouse)

Contingent Beneficiary

Additional Information

Investment Experience

Investment Information

Financial Information

All information is strictly confidential. Securities offered through Avantax Investment Services℠, Member FINRA,SIPC. Advisory services offered through Avantax Advisory Services℠, 400 S Jackson St. Jackson, MI 49201.