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
*
Single
Married
Divorced
Widowed
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
None
Less than 5 years
5-10 years
Over 10 years
Bonds
None
Less than 5 years
5-10 years
Over 10 years
Mutual Funds
None
Less than 5 years
5-10 years
Over 10 years
Options
None
Less than 5 years
5-10 years
Over 10 years
Annuities/Life Insurance
None
Less than 5 years
5-10 years
Over 10 years
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:
Ultra-conservative
Conservative
Moderate
Growth
Aggressive Growth
Primary source of funds to fund account:
Inheritance/Gift
Salary/Wages
Investment time horizon:
0-5 years
6-10 years
11-15 years
Over 15 years
Financial Information
Annual Income (all sources)
$0 - $49,999
$50,000 - $99,999
$100,000 - $199,999
$200,000 - $499,999
$500,000 - $999,999
$1m - $4,999,999
$5m - $9,999,999
Above $10 million
Net Worth (excluding residence)
$0 - $49,999
$50,000 - $99,999
$100,000 - $199,999
$200,000 - $499,999
$500,000 - $999,999
$1m - $4,999,999
$5m - $9,999,999
Above $10 million
Liquid Net Worth
$0 - $49,999
$50,000 - $99,999
$100,000 - $199,999
$200,000 - $499,999
$500,000 - $999,999
$1m - $4,999,999
$5m - $9,999,999
Above $10 million
Estimated value of all investments:
$0 - $49,999
$50,000 - $99,999
$100,000 - $199,999
$200,000 - $499,999
$500,000 - $999,999
$1m - $4,999,999
$5m - $9,999,999
Above $10 million
Tax Bracket
0%
1 - 10%
11 - 15%
16 - 25%
26 - 28%
29 - 33%
34 - 35%
Over 35%
Anything else you would like to discuss?
Upload files (example: investment statements, tax returns)
Browse Files
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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.
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