New Client Profile Form

JotForm Instructions

Please complete this form to the best of your ability. The more information you provide, the better we can serve you. For required items, place a 0 or N/A if it is not applicable to you. There will be an area for miscellaneous notes and explanations at the end of this form.

New Client Profile Form

For required items, place a 0 or N/A if it is not applicable to you.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN
Email*
example@example.com
Drivers License Number & State
Drivers License Issue Date
Drivers License Expiration Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Residence
Phone Number*
Please enter a valid phone number.
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Social Security Number
Spouse's Email
Spouse's Drivers License Number & State
Spouse's Drivers License Issue Date
Spouse's Drivers License Expiration Date
Spouse's Phone Number
Please enter a valid phone number.
Lawyer
CPA / Accountant
Property & Casualty Representative
HSA

YesNo

Children

	Name	Date of Birth	SSN	Notes
Child #1
Child #2
Child #3
Child #4

Please provide additional information if there are more than 4 children.

Beneficiaries

	Name	Relation	Percentage
Beneficiary #1
Beneficiary #2
Beneficiary #3

Employment/Income (Put a 0 if N/A)*

	Employer	Gross/Net Income	Bonus	Other Sources of Income
Self
Spouse

Financial Freedom

Our definition of financial freedom is that you no longer have to continue to work in order to pay your bills.
Your Financial Freedom Age
Spouse's Financial Freedom Age
What percentage of your current income will you need for financial? Monthly or yearly

College (future college expenses for your children)

	Name	Start Year	# of Years	Public or Private	Own Cost Estimate
Child #1
Child #2
Child #3
Child #4

Future Major Purchases

	Description	Date/Year	Cost (monthly or yearly)	Recurring?	How often?	End date
#1
#2
#3
#4

Future Private K-12 School

	Name	Start Year	# of Years	Cost (monthly or yearly)
#1
#2
#3
#4

Retirement Income

	Owner	Description	When Does Income Begin
#1
#2
#3

Assets, Liabilities, and Insurance (Savings 1 and Checking 1 Required)*

	Amount	Bank/Institution Name
Savings 1
Savings 2
Checking 1
Checking 2
CD's
Other

Investment Assets

	Owner	Description	Current Value	Additions (monthly or yearly)	Does your company match?	If yes, how much?
#1
#2
#3
#4

Assets in IRA's, College Savings Plans, Tax-Deferred Investments, and other

	Owner	Description	Current Value	Additions (monthly or yearly)
#1
#2
#3
#4

Stocks, Stock Options, and Restricted Stocks

	Owner	Description	Estimated Value	How long have you had?
#1
#2

Other Assets

	Owner	Description	Current Value	Additions (monthly or yearly)	Market Value
#1
#2
#3
#4
#5

Insurance

Life

	Policy 1	Policy 2	Policy 3	Notes
Insured
Company Name
Policy Number
Year Issued
Beneficiary
Type and Date
Death Benefit
Annual Premium
Current Cash Value

Disability

	Policy 1	Policy 2	Notes
Insured
Company Name
Amount of Benefit
Benefit Period
Annual Premium

Long-Term Care

	Policy 1	Policy 2	Notes
Insured
Company Name
Amount of Benefit
Benefit Period
Annual Premium

Medicare Supplement

	Policy 1	Policy 2	Notes
Insured
Company Name
Amount of Benefit
Benefit Period
Annual Premium

Property and Casualty

	Company Name	Premium
Auto
Home
Umbrella

Liabilities

Home and Land Loans

	1st Mortgage	2nd Mortgage	Equity Line	Line of Credit	Other
Description
Lender
Outstanding Balance
Type of Loan
Terms of Loan
Interest Rate
Monthly Payment

Vehicle Loan

	1	2	3	Notes
Description
Outstanding Balance
Monthly Payment
Interest Rate

Other Personal Data (credit cards, personal notes, education loans, etc.)

	1	2	3	4	Notes
Description
Outstanding Balance
Monthly Payment
Interest Rate

Personal Expense Worksheet

Monthly*

	Amount	Description
Mortgage/Rent
2nd/LOC
Phone
Cable/Internet
Utilities
Car Payment
Other #1
Other #2
Other #3
Other #4

Quarterly

	Amount	Description
Other #1
Other #2
Other #3
Other #4

Semi-Annual

	Amount	Description
Other #1
Other #2
Other #3
Other #4

Annual/Non-Scheduled

	Amount	Description
Christmas
Vacation
Taxes
Car Maintenance
Future Car
Home Repairs
Emergency Fund
Slush Fund

Please share any notes or comments on the information you did or did not provide.
Should be Empty:

JotForm Instructions

New Client Profile Form

Financial Freedom

Insurance

Liabilities

Personal Expense Worksheet