New Client Intake Form
Client Information
Client - Legal Name
*
First Name
Middle Initial
Last Name
Suffix
Client - Preferred Name
Nickname
Client - Gender
*
Male
Female
Client - Mobile Phone
*
Format: (000) 000-0000.
Client - Email
*
example@example.com
Client - Date of Birth
*
/
Month
/
Day
Year
Date
Client SSN
US Citizen
*
Yes
No
ID Photo Upload
Browse Files
Drag and drop files here
Choose a file
If non-US Citizen, upload Permanent Resident ID
Cancel
of
Marital Status
*
Married
Married, but only completing information for myself at this time
Single
Single, but I have another person associated with my accounts
Driver's License State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Tax Filing Status
Please Select
Single Filers
Married Filing Jointly
Head of Household
Driver's License Number
*
Driver's License Issue Date
*
/
Month
/
Day
Year
Date
Driver's License Expiration Date
*
/
Month
/
Day
Year
The next time you have to go to the DMV
Client - Employer
*
If not employed, put N/A or Retired
Client - Job Title
*
If not employed, put N/A or Retired
Client - Approximate Annual Income
*
Include Salary, Bonus, Social Security, pension, other side-income, etc.
Co-Client Information
Co-Client - Legal Name
First Name
Middle Initial
Last Name
Suffix
Co-Client - Preferred Name
Nickname
Co-Client - Gender
Male
Female
Co-Client - Mobile Phone
*
Format: (000) 000-0000.
Co-Client - Email
example@example.com
Co-Client - Date of Birth
*
/
Month
/
Day
Year
Date
Co-Client SSN
US Citizen
*
Yes
No
ID Photo Upload
Browse Files
Drag and drop files here
Choose a file
If non-US Citizen, upload Permanent Resident ID
Cancel
of
Driver's License State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Driver's License Number
*
Driver's License Issue Date
*
/
Month
/
Day
Year
Date
Driver's License Expiration Date
*
/
Month
/
Day
Year
The next time you have to go to the DMV
Co-Client - Employer
*
If not employed, put N/A or Retired
Co-Client - Job Title
*
If not employed, put N/A or Retired
Co-Client - Approximate Annual Income
*
Include Salary, Bonus, Social Security, pension, other side-income, etc.
Approximate Total Household Earned Income
Address Information
Residential Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your mailing address the same?
*
Yes
No
Mailing Address (if different)
Street Address or PO Box
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do both clients have the same address?
Yes
No
Co-Client Residential Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Co-Client - Is your mailing address the same?
*
Yes
No
Co-Client - Mailing Address (if different)
Street Address or PO Box
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Client - Primary Beneficiary Information
Would you like to list your spouse as your primary beneficiary?
*
Yes
Yes, but I'd like to have multiple primary beneficiaries
Yes, but I have a Trust I'd like my assets to flow through
No, I have a different arrangement
How many primary beneficiaries do you have?
Please Select
1
2
3
4
5
This is for PRIMARY only
Primary Beneficiary 1
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Primary Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
Yes
No
Primary Beneficiary 2
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Primary Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Primary Beneficiary 3
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Primary Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Primary Beneficiary 4
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Primary Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Primary Beneficiary 5
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Primary Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Client - Contingent Beneficiary Information
Would you like to list your children as your contingent beneficiaries?
*
Yes
Yes, but I have a Trust I'd like my assets to flow through
No, I have a different arrangement
I do not want to name a contingent beneficiary at this time
How many contingent beneficiaries do you have?
Please Select
1
2
3
4
5
This is for CONTINGENT Beneficiaries only
Contingent Beneficiary 1
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Contingent Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Contingent Beneficiary 2
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Contingent Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Contingent Beneficiary 3
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Contingent Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Contingent Beneficiary 4
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Contingent Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Contingent Beneficiary 5
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Contingent Beneficiary SSN
Percentage Share
*
Must be a whole number
Per Stirpes?
*
Yes
No
Final Questions
How did you hear about us?
*
Please Select
Personal Connection
Word of Mouth
Internet
Magazine
Please Specify
Internal Use Only
Fidelity Advisor Code
*
Please Select
G40341373
G42784211
G-Haas
G - M,B,A
G-Raiteri
Schwab Advisor Code
Please Select
S - Brandon
S - Alex
S - Matt
S - M,B,A
S - B,A
S - Brian
Related Advisors
*
Please Select
Brandon Grable & Alex Richmond
Brandon Grable & Matt Haas
Matt Haas
Matt Haas, Brandon Grable, & Alex Richmond
Brian Raiteri
Wealthbox Client Assignment - Advisor
*
Please Select
Brandon Grable
Alex Richmond
Matt Haas
Brian Raiteri
Advisor Email
*
example@example.com
END
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