Please return 5 days prior to your appointment via mail, email, or fax:
Documents to return with this form (checked items only):
Berlin: P.O. Box 250, Berlin, OH 44610
Email: [email protected]
Phone: 330.893.0113 Fax: 330.893.3339
☐ Copies of recent investment statements for all
investment accounts, IRAs, 401(k)s, etc
Confidential Client Intake Form
☐ Current household income numbers
☐Current life insurance statements
Prior to our first meeting, please take a few minutes to fill in some basic information
about yourself and your family. This form will help me get a general idea of your
financial picture and prepare for our first meeting.
☐ Most recent Social Security benefit statement for each
client from http://www.socialsecurity.gov/mystatement/
☐ Other: __________________________
Client Name: _____________________ Spouse Name: ___________________
Date of Birth: ____________________ Spouse Date of Birth: ______________
Phone #:_________________________ Spouse Phone #:_________________
Appointment Date/Time: ___________________________________________
Meeting with: ____________________________________________________
1. How May We Communicate With You?

Preferred method to contact you to setup appointments, ask general questions, etc.?
___ Phone Call __ Email ___ Text ___ US Mail

To send sensitive information (account specific), may we correspond with you via secure* email?
*our email is strongly encrypted, password-protected, and easy to use.
___ Yes ___ No, prefer US mail
2. Tell Us About Your Family: Please list children and other dependents
Name
Relationship
Date of Birth
Dependent
Married
(Y/N)
(Y/N)
Residence
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. Place an “x” by each statement using a scale of 1-5, or n/a (1 not accurate at all, 5 very accurate, n/a for not applicable)
I know where my income goes each month.
I am happy living at my current home.
I am satisfied with my current career and the income it provides.
My family, relationships, & inner-peace are not affected by money stress.
I am comfortable with my current amount of debt.
I set goals for short, medium, and long-term wants and needs.
If I passed away today, I am confident my loved ones will remain financially stable.
I understand how my investments fit into my broader financial plan.
I clearly understand my company retirement plan and benefits.
I am saving toward retirement and know my future retirement needs will be met.
I save at least 10% of my income each month.
I enjoy watching the S&P 500 or Dow Jones Index on a weekly basis.
I reacted appropriately when the stock market declined in 2008.
1
2
3
4
5
N/A
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4. Employment, Earnings, Spending & Saving:
Client 1:
Client 2:
Employer
__________________________
__________________________
Title/Job
__________________________
__________________________
Years with Employer
__________________________
__________________________
Salary
__________________________
__________________________
Bonus/Commissions
__________________________
__________________________
Self-Employment Income
__________________________
__________________________
Other Earned Income
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
(Pension, SS, Alimony, etc)
Total Current Year
Is income fairly reliable?
5. Retirement Contributions and Savings
Client 1
Client 2
Do you currently contribute on a regular basis to a company retirement plan? If yes, how much ($/%)?
_______
_______
Do you currently save in an individual retirement account (Roth/IRA)? If yes, how much?
_______
_______
Do you currently contribute into other savings accounts? If yes, how much?
_______
_______
6. Debt
Do you find the monthly payments easy to manage? y/n If no, elaborate. ____________________________________________________________
________________________________________________________________________________________________________________________
7. Assets (401k, Bank Savings, Investment Accounts, etc)
Estimated Value
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
8. Liabilities (Mortgage, Car Loan, Credit Cards, School Loans, etc)
Estimated Value
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
___________________________________________________________________________ _____________________________
Client 1
Client 2
Do you have a will? y/n, if yes, Have you reviewed it in the last 3 years?
______
______
Do you have a trust? y/n, if yes, Have you reviewed it in the last 3 years?
______
______
If you have a trust, have you funded the trust?
______
______
Do you have a Durable Power of Attorney?
______
______
Do you have a health care proxy?
______
______
9. In a few words, tell us why you want to meet:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Thank you – looking forward to meeting you soon!
Pleasant conversations for hope
and a better future.