Secure Account Initiation Questionnaire

Completing this brief questionnaire will provide us with the information we need to begin working toward a long-term plan to reach your financial goals. Once we receive the completed form, we'll contact you to schedule a personal consultation to more thoroughly explore your unique financial situation, discuss your long-term goals, and answer any questions you may have.

1. Personal Information

First name:
Middle name:
Last name:
Suffix:
Birth date:
Driver's license number:
Driver's license state:
Social Security number:
Citizenship status:	US citizen Resident alien
Residence address:
Residence city:
Residence state:
Residence zip:
Mailing address: (if different)
Mailing city:
Mailing state:
Mailing zip:
Home phone:
Cell phone:
Work phone:
Email address:
Marital status:	Single Married Widowed Divorced
Occupation:
Employer name:
Employer address:
Employer city:
Employer state:
Employer zip:

2. Spouse Information (if applicable)

Spouse's first name:
Spouse's middle name:
Spouse's last name:
Spouse's suffix:
Spouse's birth date:
Spouse's driver's license number:
Spouse's driver's license state:
Spouse's Social Security number:
Spouse's citizenship status:	US citizen Resident alien
Spouse's home phone:
Spouse's cell phone:
Spouse's work phone:
Spouse's email address:
Spouse's occupation:
Spouse's employer name:
Spouse's employer address:
Spouse's employer city:
Spouse's employer state:
Spouse's employer zip:

3. Dependent Information (if applicable)

Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:
Name:		Birth date:		SSN:		Relationship:

4. Automatic Transfers

Would you like us to help you set up automatic deposits to or withdrawals from your accounts?	Yes No
Would you like us to help you set up an electronic funds transfer (EFT) link to your bank account?	Yes No

5. Assets and Liabilities

Assets	Value ($)	Liabilities	Balance ($)
Stocks		Mortgages
Bonds		Auto loans
Real estate		Other debts
Family business (net)
Cash or money market
Other assets
Total assets		Total liabilities

6. Income

Earned income	Annual amount ($)	Other income	Annual amount ($)
Wages		Social Security
Spouse's wages		Pension
Other earned income		Interest and dividends
		Other unearned income
Total earned income		Total other income

7. Investment Accounts

Account type (Individual, Joint, Trust, Traditional IRA, Roth IRA, SEP-IRA, etc.)	Where held	Balance ($)