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Client Questionnaire

CONFIDENTIAL This questionnaire is designed to help us gather information necessary to properly advise you. You may ignore the questions that do not apply to you. Whether you are a new or an existing client, this questionnaire is extremely helpful and we ask your indulgence in completing it fully.

Step 1 of 9

Name
This field is for validation purposes and should be left unchanged.
How did you hear about us?
Person Completing the Form
First Last
Relationship to Client
SECTION 1. NAME AND CONTACT INFORMATION
CLIENT DETAILS
FULL LEGAL NAME (as it appears on Government Issued ID)
First Middle Last
Gender
- Male
- Female
Also known as
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is Mailing Address the Same as Home Address?
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Date of Birth
US Citizen?
- Yes
- No
Veteran?
- Yes
- No
Email
It is OK to communicate with me via my E-mail address?
- Yes
IMPORTANT NOTICE: Please use a personal e-mail address rather than a work e-mail address. There is no attorney-client privilege extended to communications transmitted through your employer e-mail address.)
Relationship
- Married
- Divorced
- Widow
- Single
- Domestic Partnership
Date of Marriage
Do you have a prenuptial agreement
- Yes
- No
Do you have a postnuptial agreement
- Yes
- No
Additional Clients
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Certified Public Accountant
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Financial Advisor:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email

Additional Clients
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SECTION 2. CHILDREN
List all children.
Total number of children
Full Legal Name
Date of Birth
Parent
- Client #1
- Client #2
- Both
Gender
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is Child's Mailing Address the Same as Home Address?
Child's Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Mobile Phone
Email
Child
- Deceased
- Adopted
Date of Deceased
Date of Adoption
Child has surving children?
- Yes
- No
Additional Children Details
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Additional Children Details
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SECTION 3. OTHER AGENTS/BENEFICIARIES
If you wish to designate individuals other than your children, please provide their information below.
Full Legal Name
First Last
Date of Birth
Agent's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is Agent's Mailing Address the Same as Home Address?
Agent's Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Gender
- Male
- Female
Relationship
Addtional Agent or Beneficiary
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Addtional Agent or Beneficiary
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SECTION 4. ASSETS AND INCOME
A. FIXED MONTHLY INCOME
Social Security Amount
Client #1 Client #2 Joint? (Answer Yes or No)
Pension Amount
Client #1 Client #2 Joint? (Answer Yes or No)
Other Assets
Client #1 Client #2 Joint? (Answer Yes or No)
SECTION 4. ASSETS AND INCOME
B. NON-FIXED MONTHLY INCOME
Interest Amount
Client #1 Client #2 Joint? (Answer Yes or No)
Dividends Amount
Client #1 Client #2 Joint? (Answer Yes or No)
Client 1 Total
Client 2 Total
Joint? Answer Yes or No
Cash and Bank Accounts (CD, Checking, Savings, etc.)
Name of Bank/Branch Type of Account Balance/Value How Title Held
Additional Bank Accounts
Name of Bank /Branch
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Securities (Bonds, Marketable Securities, etc.)
Name of Company #Shares/Face Value Current Value How Title Held
Securities
Name of Company
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Section 4: Retirement Accounts (IRA, 401K, 403b, Keoghs, etc.)
Retirement Accounts (IRA, 401k, 403b, Keoghs, etc.)
Name of Insitution Owner Beneficary/Contigent Bene. Current Value
Non-Retirement Accounts (IRA, 401k, 403b, Keoghs, etc.)
Name of Insitution Owner Beneficary/Contigent Bene. Current Value

Name of Bank /Branch
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Name of Company
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Section 5: Real Estate
PRIMARY RESIDENCE
A. OWNERS
Fair Market Value
Mortgage Balance
Is it a Reverse Mortgage?
- Yes
- No
If the property was PURCHASED, please provide the following:
Date of Purchase
Purchase Price
If the property was INHERITED, please provide the following:
Month/Year Inherited
Value when Inherited
D. REAL ESTATE OTHER THAN PRIMARY RESIDENCE
(Including Timeshares, Co-Ops, Vacant Land, Etc.)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How Title Held
Cost Basis
Market Value
Mortage Balance
Additional Residence
Address
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Address
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Name of Insurer
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Name of Insurer
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Name of Insurer
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Personal Property
Home Furnishings
Market Value How Title Held
Cars, RVs, Boats, Etc.
Market Value How Title Held
Jewels, Fur, etc
Market Value How Title Held
Fire Arms
Market Value How Title Held
Other
Market Value How Title Held
Section 9. Client Goals
What are your goals for your estate plan?
Consent*
* I have answered the above questions accurately and to the best of my ability. I understand that any recommendations made will be based on the information given and any additional or varying information may negate any advice that was previously provided to me.

Client Questionnaire

Step 1 of 9

SECTION 1. NAME AND CONTACT INFORMATION

Certified Public Accountant

SECTION 2. CHILDREN

SECTION 3. OTHER AGENTS/BENEFICIARIES

SECTION 4. ASSETS AND INCOME

SECTION 4. ASSETS AND INCOME

Section 4: Retirement Accounts (IRA, 401K, 403b, Keoghs, etc.)

Section 5: Real Estate

If the property was PURCHASED, please provide the following:

If the property was INHERITED, please provide the following:

D. REAL ESTATE OTHER THAN PRIMARY RESIDENCE

Section 6: Life Insurance

Section 7. Long-Term Insurance

Section 8. Health Insurance

Personal Property

Section 9. Client Goals

Step 1 of 2

Section 6: Insurance