Pacifica Initial Client Interview Form Page Initial Client Interview Form Data gathering is the first step in the financial planning process. Unless required by law, information provided in this profile will not be released without client consent. Client Name:AgePhone NumberDate of Birth Month Day Year Employer/ProfessionSpouse/Partner’s Name:AgeDate of Birth Month Day Year Employer/ProfessionHome Address:Home#:Bus#:Fax#:Client Email: Spouse/Partner Email: 1. What is your primary motivation for contacting a financial planner at this time?2. What are your most important financial concerns?a)b)c)d)3. What are your most important non-financial concerns & objectives right now?a)b)c)d)4. What kind of service/relationship do you desire with a financial adviser?5. Have you ever worked with a financial advisor before? Yes No What was good/bad about that experience?6. Approximate Monthly Income7. Approximate Monthly ExpensesApproximate Monthly ExpensesDo you own or are you a decision maker for a business? Yes No 9. What changes do you expect in the future that you wish to plan for?Family obligations:Inheritances:Other:12. Have you been a resident of another state? Yes No If yes, which states and when:14. Is there anything else we need to talk about? Any “special needs” situations you are responsible for? Threat Matrix: Asset Protection Questionnaire We believe in making sure our client’s assets are protected. This asset protection questionnaire we created was featured on Forbes. Please select all that apply: Do you have assets exceeding $500,000? Are you on the board of a company or non-profit? Do you have household help? Do you have a small business you operate as a sole proprietorship? Do you have a business where you have a partner but not a corporation or LLC? Do you have a child who drives your automobile? Do you or your employees use your automobile in your business? Do you have a dog? Do you have rental property with tenants? Do you have a boat, Jet Ski, or motorcycle? Do you have the minimum insurance coverage on your automobile and/or home? Do you have an umbrella liability insurance policy? Are you a public figure (e.g., politician, actor, athlete, musician)? Do you have joint bank or investment accounts with others? Are you an active user of Twitter, Facebook, or other social media? Does your company provide a retirement plan for employees? Do you have non family member employees? Is your income or wealth public information? Do you throw parties at your home? Do you have adequate amounts of liability insurance through your company (e.g., errors and omissions, malpractice, employment practices, etc.)? Do you have a swimming pool? Are you a physician or in a similar risky profession? Do you own a horse? Net Worth Statement Please give us a rough idea of your assets and liabilities so we can start preparing a more detailed list of questions needed to properly advise you. For this page, all we’re looking for are estimated dollar amounts. We’ll go into much more detail regarding your assets later in the process, if needed. We can total everything for you if you wish. CASH EQUIVALENTS: REAL ESTATE DEBT: Checking & Savings Accounts1st Mortgage onMoney Market Accounts2nd Mortgage on ResidenceCDs (Certificates of Deposit)Loans on Other ResidencesT-BillsAll Rental MortgagesLife Insurance Cash Values(↑ Not death benefit) Subtotal: SECURITIES (NON-CASH): OTHER LIABILITIES: Individual Bonds or NotesAll Vehicle LoansMutual FundsCredit Card Debt (not paid off monthly)Fixed AnnuitiesAll Aircraft & Boat LoansVariable AnnuitiesInvestment/Margin LoansIndividual StocksBusiness LoansLimited partnershipsLife Insurance/401(k)All Other Debt or Loans OTHER SECURITIES: IRAs/Keoghs/TSAs/401(k)sPrecious MetalsESOP/Employer Stock OptionsBusiness Interests (Assets)NET WORTH:Loans Payable to YouRental Real EstateRaw Land & Other Real Estate PERSONAL EFFECTS: Personal ResidenceGems, Artwork, CollectionsAutos & Personal Effects
