New Client Information

New Client Information

CONFIDENTIAL
New Client Information
Primary Owner Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number

Area CodePhone Number
Email
example@example.com
Social Security Number
Birth Date

MonthDayYear
Date
Drivers License Number
Issue Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Marital Status
Number of Dependents
Employer
Position/Title
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number

Area CodePhone Number
Spouse Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number

Area CodePhone Number
Drivers License Number
Issue Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Primary Beneficiary (leave blank if spouse)
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Social Security Number
Beneficiary Percentage
Birth Date

MonthDayYear
Date
Add Beneficiary 2?
Type of Beneficiary
Beneficiary Percentage
Beneficiary Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Relationship
Phone Number

Area CodePhone Number
Add Beneficiary 3?
Type of Beneficiary
Beneficiary Percentage
Beneficiary Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Relationship
Phone Number

Area CodePhone Number
Additional Information
Do you have a will or trust?
Name and date of trust:
Do you have any other investment accounts?
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?
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)
Investment Information
Investment Objective:
Primary source of funds to fund account:
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 (ex. investment statements, tax returns, policy statements, etc.)

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℠, 408 W. Michigan Ave, Jackson, MI 49201.
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