New Client Questionnaire

Name*

First NameLast NameNickname

Address*

NO P O BOX/ PHYSICAL ADDRESS ONLY

Street Address Line 2

CityST

ZIP Code

Any Personal Financial Questions, Issues, Concerns You Would Like To Discuss?

0/300

Social Security Number*

Date of Birth*

MonthDayYear

Occupation*

Or, retired, student, etc.

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Spouse/Partner Information

First NameLast NameSuffix

Spouse Social Security Number

Spouse Date of Birth

MonthDayYear

Spouse Email

example@example.com; please re-enter your email.

Spouse Phone Number

Please enter a valid phone number.

Spouse Occupation

Or, retired, student, etc.

Address (if different from Spouse/taxpayer)

NO P O BOX/ PHYSICAL ADDRESS ONLY

Street Address Line 2

CityST

ZIP Code

Dependents: Child, stepchild, sibling, parent, or other relative you provide support for. We will gather this information when we speak.

I have dependents*

YesNo

Other Income (check all that apply)

Health insurance:*

Employer-providedhealth insurance marketplace (such as Connecticare or Husky)Medicare (65 or over)Other

Tuition:

I paid tuition for myself or my dependent (Form 1098-T)