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Personal Information
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
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Single
Married
Divorced
Widowed
Number of Dependents
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00
01
02
03
04
05
Under 18 or Financial Dependent
Tax Residency
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Western Sahara
Yemen
Zambia
Zimbabwe
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Employment
Employment Status
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Employed
Retired
Self-Employed
Entrepreneur
Student/inter
Unemployed
Full Employer Name
If Self-Employed: Business Name
Nature of Business
Please Select
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Arts/Design
Community/Social Service
Computer/Information Technology
Construction/Extraction
Education/Training/Library
Farming, Fishing and Forestry
Finance/Broker Dealer/Bank
Food Preparation and Servicing
Healthcare
Installation, Maintenance, and Repair
Legal
Life, Physical and Social Science
Marijuana/Cannabis
Media and Communications
Military/Law Enforcement, Government, Protective Service
Personal Care/Service
Occupation
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Spouse
Spouse Name
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First Name
Middle Name
Last Name
Spouse Date of Birth
-
Month
-
Day
Year
Date
Spouse Email
*
example@example.com
Spouse Phone Number
Please enter a valid phone number.
Spouse Phone Number
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Country Code
-
Area Code
Phone Number
Spouse Employment Status
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Employed
Retired
Self-Employed
Entrepreneur
Student/inter
Unemployed
Spouse Full Employer Name
Spouse Occupation
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Dependents
Dependent Name
First Name
Middle Name
Last Name
Dependent Date of Birth
-
Month
-
Day
Year
Date
dependent2
Dependent 2 Name
First Name
Middle Name
Last Name
Dependent 2 Date of Birth
-
Month
-
Day
Year
Date
dependent3
Dependent 3 Name
First Name
Middle Name
Last Name
Dependent 3 Date of Birth
-
Month
-
Day
Year
Date
dependent4
Dependent 4 Name
First Name
Middle Name
Last Name
Dependent 4 Date of Birth
-
Month
-
Day
Year
Date
dependent5
Dependent 5 Name
First Name
Middle Name
Last Name
Dependent 5 Date of Birth
-
Month
-
Day
Year
Date
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Financial Informations
Annual Income (USD)
Net Worth (USD)
Please Select
< 5,000
5,000 - 19,999
20,000 - 49,999
50,000 - 74,999
75,000 - 99,999
100,000 - 249,999
250,000 - 499,999
500,000 - 999,999
1,000,000 - 1,999,999
2,000,000 - 4,999,999
5,000,000 - 9,999,999
10,000,000 - 24,999,999
25,000,000 - 29,999,999
30,000,000 - 49,999,999
> 50,000,000
Total value of assets and goods, ex: Real Estate, Boat, Car, Investments, Checking Account and etc…
Liquid Net Worth (USD)
Please Select
< 5,000
5,000 - 19,999
20,000 - 49,999
50,000 - 74,999
75,000 - 99,999
100,000 - 249,999
250,000 - 499,999
500,000 - 999,999
1,000,000 - 4,999,999
> 5,000,000
Total Net Value, ex: Investments, Checking Account, Savings and etc…
Bonuses (USD)
Additional Income Sources? (USD)
Yes
No
Additional Amount (USD)
Additional Income Details
spouse_income.
Spouse Annual Income (USD)
Spouse Bonuses (USD)
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Debt and Expense management
Owns a House or Rent?
Owns
Rent
Paid Off?
Yes
No
Monthly Living Expenses: (USD)
Mortgage Amount/Monthly Rent: (USD)
If you died, do you want to pay your mortgage off?
Yes
No
Why not?
Do you have any major debts?
Yes
No
Debts Details and Amount
Do you have a college fund?
Yes
No
College Fund
How much and where?
Do you think it is important to have a college fund?
Yes
No
How do you plan on paying for college?
How much do you think college costs per year?
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Objectives
How long would you like working at your present job vs. doing something else?
Do you have specific financial objectives?
Do you have specific financial objectives for:
The short term?
The mid term?
The long term?
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Savings
Do you currently have any savings?
Yes
No
Amount: (USD)
Do you systematically save?
Yes
No
Amount Save (USD)
Frequency
Please Select
Monthly
Year
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Investments
Do you currently have any investments account?
Yes
No
Amount: (USD)
investments?
Stock ($)
Investment Fund ($)
Bonds ($)
Retirement ($)
BDR / International Funds ($)
Others:
Abroad Account?
Yes
No
Name of the bank?
Amount?
What is the purpose of these investments
Long Term
Short Term
Purpose details
What do you like about these investments?
Is there anything you do not like or would improve?
Are you happy with the service you receive and the correspondence/attention?
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Qualified plans
Retirement Savings / Amount in Account
Type off Account/Investment
Do you have a 401(k) plan?
Yes
No
Do you fully fund your plan?
Yes
No
If yes, would you put in more money if you could?
Yes
No
How much?
If no, why?
Do you have any old IRA’s or 401(k)s floating around?
Yes
No
What type? Where are they invested? When was it last reviewed?
Does your spouse have any old IRAs or 401(k)s?
Yes
No
If yes, what type? Where are they invested? When was it last reviewed?
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Life insurance
Do you have life insurance?
Yes
No
life_insurance
Total Amount:
Type of Life Insurance
Whole Life
Universal
Variable
Does your spouse have life insurance?
Yes
No
Spouse Amount:
Type
If Term: Why did you purchase term rather than a cash value policy? / If Cash Value: Did you buy for death benefit, cash value or both?
Do you have any idea how much life insurance you should have?
Yes
No
Do you feel you have enough insurance?
Yes
No
How did you come up with the amount?
When was the last time you reviewed your policies?
Have you done estate planning and placed them into trusts?
Are you and your spouse U.S. citizens?
Yes
No
Are you and your spouse insurable?
Yes
No
Information on policies (company, type, premium, face amount, cash value, etc...)
Do you understand your group benefits?
Yes
No
Have DI coverage?
Yes
No
Do you have LTC coverage?
Yes
No
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Health insurance
Do you have health insurance?
Yes
No
Describe your plan
Type of coverage
Disability Coverage?
Yes
No
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