Client Discovery & Initial Prequalification Form

Please complete this confidential questionnaire to help us understand your financial landscape.

Client Information

Full Name

Preferred Name

Date of Birth

Marital Status

City & State Reside in

Occupation

Employer / Business

Annual Income

Cell Phone

Spouse / Partner Information

Full Name

Date of Birth / Age

Occupation

Employer / Business

Children

Name	DOB / Age	Sex	Marital Status
		MF
		MF
		MF
		MF
		MF
		MF

Household Income

Employment Income

Business Income

Rental Income

Investment Income

Other Income

Estimated Total Annual Household Income

Estimated Net Worth

	#1	#2	#3
Cash & Bank Accounts
Money Market / CDs
Brokerage Accounts
Retirement Accounts
Business Interests
Real Estate Equity
Other Assets
Estimated Total Net Worth

Residential Real Estate

	Property #1	Property #2
City, State & Zip Code
Primary Residence?	YesNo	YesNo
Current Estimated Market Value
Original Purchase Price
Purchase Year
Remaining Mortgage Balance
Monthly Mortgage Payment
Estimated Equity
HELOC Balance
Other Liens or Judgments

Investment / Commercial Real Estate

	Property #1	Property #2
Property Type
City, State & Zip Code
Ownership %
Current Market Value
Remaining Mortgage
Annual Rental Income
Estimated Annual Cash Flow
Estimated Equity
Existing Liens

	Property #3	Property #4
Property Type
City, State & Zip Code
Ownership %
Current Market Value
Remaining Mortgage
Annual Rental Income
Estimated Annual Cash Flow
Estimated Equity
Existing Liens

Business Information (If Applicable)

	Business #1	Business #2
Business Name
Industry
Ownership Percentage
Estimated Business Value
Annual Revenue
Estimated Annual Profit
Outstanding Business Loans
Existing Liens

Outstanding Debts

Residential Mortgages

Commercial Mortgages

Business Loans

Lines of Credit

Investment Loans

Personal Loans

Other Debts

Existing Life Insurance

Insurance Company	Policy Type	Death Benefit	Annual Premium	Cash Value	Policy Loan

Health Information

Height

Weight

Tobacco / Nicotine?

YesNo

Current Medical Conditions

Current Medications

Major Surgeries / Hospitalizations

Family Medical History

Banking Relationships

Primary Bank (such as Bank of America, Chase etc)

Private Banking Relationship?

YesNo

If yes (name of bank / lender)

Existing Securities-Based Lending?

YesNo

Other Credit Facilities

Estate Planning

Do you currently have:

WillRevocable Living TrustIrrevocable TrustILITEstate Planning AttorneyPower of AttorneyHealthcare DirectiveCPAFinancial Advisor

Current Financial Concerns

Please check all that apply.

Family & Legacy

Leaving an inheritanceMulti-generational wealth transferEqual inheritance among childrenProtecting heirs from creditors/divorceFamily governanceSpecial needs planning

Taxes

Estate taxIncome taxCapital gains taxRequired Minimum Distributions (RMDs)Tax-efficient wealth transfer

Retirement

Lifetime incomeAsset preservationRetirement cash flowLong-term careInflation

Business

Business successionBuy-Sell AgreementKey Person InsuranceExecutive Bonus PlanningBusiness continuation

Asset Protection

Lawsuit protectionCreditor protectionReal estate protectionLiquidity for estate settlement

Investments

Portfolio diversificationTax-efficient investingConcentrated stock positionsLow investment returnsExcess idle cash

Premium Finance

Preserve liquidityLeverage existing assetsMaximize life insuranceEstate liquidityWealth transferMulti-generational legacyPrivate banking strategies

Other

Goals

What are your top three financial goals?

Desired Life Insurance Coverage

Desired Annual Premium Budget

Target Retirement Age

Documents to Provide (If Qualified)

Last two years' tax returnsPersonal Financial StatementExisting life insurance statementsBrokerage statementsBank statementsBusiness financial statementsTrust documentsDriver's license or Passport

Signatures

Client Signature:Date:

All information is kept strictly confidential and used solely for advisory purposes.