Getting To Know You The information on this form with help us get to know you better. You can answer as few or as many of the questions as you wish. We keep all of the information you provide confidential. NameThis field is for validation purposes and should be left unchanged.Name First Last Date of Birth Month Day Year Phone NumberBusiness Phone NumberEmail Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you need to add information for a spouse / partner? Yes No Spouse Name First Last Spouse Date of Birth Month Day Year Spouse Email What is your primary motivation for contacting us?What are your most important financial concerns?What are your most important non-financial concerns & objectives right now?What kind of service/relationship do you desire with a financial adviser?Have you worked with a financial advisor in the past? Yes No What did you like / dislike about your experience with the advisor?Do you own or are you a decision maker for a business? Yes No What changes do you expect in the future that you wish to plan for? Business Sale College/Education Planning Divorce Family Obligations General Financial Planning Inheritance Lawsuit Settlement Retirement Is there anything else we need to talk about? Any “special needs” situations you are responsible for?Threat Matrix: Asset Protection QuestionnaireWe believe in making sure our client’s should this be clients' assets are protected. Our asset protection questionnaire was featured on Forbes.Please select any that apply to you Have assets exceeding $500,000 Are you on the board of a company or non-profit Have household help Have a small business you operate as a sole proprietorship Have a business where you have a partner but not a corporation or LLC Have a child who drives your automobile Do you or your employees use your automobile in your business Have a dog Have rental property with tenants Have a boat, Jet Ski, or motorcycle Have the minimum insurance coverage on your automobile and/or home Have an umbrella liability insurance policy Are you a public figure (e.g., politician, actor, athlete, musician) 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 Have non-family member employees Is your income or wealth public information Do you throw parties at your home Have adequate amounts of liability insurance through your company (e.g., errors and omissions, malpractice, employment practices, etc.) Have a swimming pool Are you a physician or in a similar risky profession Do you own a horse Net Worth Statement: AssetsCashe.g., bank accounts, CDs, etc.Business OwnershipRetirement Accountse.g., 401k, IRAs, etc.Non-Retirement AccountsReal EstateOtherTotal AssetsNet Worth Statement: DebtsMortgageCredit CardsOtherTotal LiabilitiesApproximate Net WorthAdditional Tools and ResourcesWould you like to: Signup to receive a free six-part video course on how to become a better investor Subscribe to a weekly newsletter of articles and research at the intersection of personal finance and personal development Download an abridged version of the Sudden Wealth Solution eBook Get more information on Robert's Pacifica Wealth Podcast Please check the boxes of the items you're interested in. You may change your preferences anytime.Upload Documents Drop files here or Select files Accepted file types: pdf, doc, docx, xlsx, csv, jpg, png, Max. file size: 50 MB. Your documents will be uploaded to a secure folder with Dropbox
