New Client Questionnaire

Your information is secure and for internal use only.

Name

First Name

Last Name

Phone Number

(###)

###

####

Life Insurance Information

Life Insurance

Life Insurance Carrier

Face Amount

Retirement & Social Security Information

Retired?

Retirement date goal

YYYY

Retirement income goal

Are you taking Social Security?

If yes, monthly social security amount

If no, when do you expect to take Social Security?

Is your spouse retired?

Spouse retirement date goal

YYYY

Spouse retirement income goal

Is your Spouse taking Social Security?

If yes, monthly amount:

If no, when do they expect to take Social Security?

Please list household source of income and monthly amount:

Beneficiary

Account Primary Beneficiary:

Account Contingent Beneficiary:

Trusted Contact

First Name

Last Name

Trusted Contact Phone Number

(###)

###

####

Trusted Contact Relationship

Spouse

Family Member

Child

Friend

Other

Professional Preferences

Accountant Name

First Name

Last Name

Attorney Name

First Name

Last Name

Real Estate Holdings

Primary Residence

Mortgage Amount, Years Remaining and Interest Rate, Timestamped Value

Secondary Residence

Mortgage Amount, Years Remaining and Interest Rate, Timestamped Value

Investment Property

Mortgage Amount, Years Remaining and Interest Rate, Timestamped Value

Liabilities

Other Assets

Business Interest, Expected Inheritance, Outside Assets, etc.

Net Worth

Liquid Net Worth

Everything excluding real estate, personal effects and vehicles.

Will or Estate Plan

Next/Immediate Financial Goals

Questions or Concerns?

1729 Allentown Road
Lima, OH

timothy.sielschott@lpl.com
Phone: 567-712-2414
Fax: 567-712-6389