Consultation Data Form

*Required Fields

Client #1 Information

Street address, P.O. box, company name, c/o

Apartment, suite , unit, building, floor, etc.

* If retired, provide prior occ and employer

Street address, P.O. box, company name, c/o


In the next five years, how much of your investments or savings do you plan on spending?

Do you have a Financial Power of Attorney?

Do you have a Living Will/Healthcare Advance Directive?

Do you have a will?

Do you expect to support someone outside of normal dependent support (handicapped child, parent, etc)?

Do you expect to receive an inheritance?


Type: PS = Passbook Savings; MM = Money Market; TB = Treasury Bills; I = IRA; R = Roth; 4T = Traditional 401K; 4R = Roth 401(k); SI = SEP-IRA; T = TSA or 403B; S = Stock; MF = Mutual Funds; RE = Real Estate Investment Trust; B = Bonds; CD = CDs; O = Other (explain)

*If your employer matches any contributions, please list amount along with your contribution


Type: T = Term*; U = Universal Life; V = Variable Life; VL = Variable Universal Life; W = Whole Life; VA = Variable Annuity; LT = Long-Term Car; DI = Disability; FA = Fixed Annuity

Pensions & Social Security
Real Estate Investments

Type: PR = Primary Residence; SR = Secondary Residence; RR = Rental Residential; RC = Rental Commercial; O = Other
#: F = First Mortgage; S = Second Mortgage


Item/Company: Auto, Credit Cards, Student Loans, Charitable Giving, etc.

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All recommendations are based upon the information provided by you and other information disclosed in discussions. Any failure to provide complete information or to advise of material changes to retirement plans or financial situation may render such retirement planning recommendations invalid