CLIENT PROFILE
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BASIC INFORMATION
Name
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Your Phone Number
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Phone Number
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Date
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Day
Year
Date
Your Address
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Street Address Line 1
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Marital Status
Married
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Significant Other
Spouse's Name
First Name
Last Name
Spouse's Birth Date
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Significant Other
First Name
Last Name
Significant Other DOB
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Month
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Day
Year
Date
Any Children?
Yes
No
Please list names and DOBs
Ex: John Doe 9/11/2015
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PROFESSION & INCOME
Your Profession or Title?
*
Annual Income
*
Put N/A if None
Your Employer
*
Put N/A if None
How Long?
Do You Receive Any Additional Monthly Income?
None
Social Security
Disability
Alimony
Child Support
Retirement or Pension
Rental Property (provide details during appt)
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LIVING EXPENSES & LOANS
Housing (renting)
*
Own
Rent
Living rent free with family or friends
Monthly Rent or Mortgage
N/A if None
Interest Rate
%
Balance of Mortgage
Loan Debts (Type / Approximate Balance / Rate) Ex: Credit Card, Car Loan, Student Loan...
Utilities (Type / Approximate Balance / Rate) Ex: Gas, Water, Electric, Phone, Internet
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INSURANCE & PROTECTION
Approximate Monthly Premium: Auto + Home Ins
Do you have any of the following Additional Insurance Protection?
Cancer Insurance
Accident Insurance
Disability Insurance
Umbrella Insurance
What Type of Life Insurance Do You Have?
Group (through employer)
Term (temporary - covers specific amount of years)
Permanent (has cash value)
None
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ASSETTS
Your Retirement Accounts?
Current 401k/403b/457/TSP
Old 401k/403b/457/TSP
IRA
Roth
None
Approx Retirement Value (current)
Approx Retirement Value (old)
College Savings (529 or other savings)
How Much Do You Feel You Have Left Over After All The Bills Are Paid?
*
Do You Have? (Click all that Apply)
Will & Testament
Trust
Power of Attorney
Health Proxy
What Is Your Biggest Financial Headache?
understanding how money works
Notes | Questions | Comments
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