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?

YesNo
Type of Beneficiary*

ContingentPrimary
Beneficiary Percentage
Beneficiary Name*

First NameLast Name
Social Security Number
Date of Birth*

MonthDayYear
Date
Relationship
Phone Number

Area CodePhone Number
Add Beneficiary 3?

YesNo
Type of Beneficiary*

ContingentPrimary
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?

YesNo
Name and date of trust:
Do you have any other investment accounts?

YesNo
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 InsuranceLong 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/GiftSalary/WagesBusiness RevenueOther
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.
Should be Empty:

CONFIDENTIAL

New Client Information

Primary Owner Information

Spouse Information

Primary Beneficiary (leave blank if spouse)

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