Intake Form - Belinda Petshow Investment Services

- Step 1 of 5

Your Personal Information

Your Name *

First

Middle

Last

Date of Birth *

Last 4 Digits of Social Security Number (SSN) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone *

Secondary Phone

Email *

Preferred Contact Method

Employer/Occupation

Are you retired? *

Industry

Firm Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Volunteer Organizations

How many organizations are you a part of?

Organization Name

Your Position Title

Date Joined

Organization Name

Your Position Title

Date Joined

Organization Name

Your Position Title

Date Joined

Your Relationships

Trusted Contact/Spouse/Business Partner

Please select any of the following that you would like to add:

Spouse
Business Partner
Other Trusted Contact

Spouse

Is this person also a Trusted Contact? *

Does this person share your address? *

Full Name *

First

Middle

Last

Anniversary

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Business Partner

Is this person also a Trusted Contact? *

Full Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Trusted Contact

Does this person share your address? *

Full Name *

First

Middle

Last

Relationship

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Children/Grandchildren

How many children and grandchildren do you have? *

Child/Grandchild 1

Child
Grandchild

Is this person a beneficiary? *

Does this person share your address?

Full Name *

First

Middle

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child/Grandchild 2

Child
Grandchild

Is this person a beneficiary? *

Does this person share your address?

Full Name *

First

Middle

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child/Grandchild 3

Child
Grandchild

Is this person a beneficiary? *

Does this person share your address?

Full Name *

First

Middle

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child/Grandchild 4

Child
Grandchild

Is this person a beneficiary? *

Does this person share your address?

Full Name *

First

Middle

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child/Grandchild 5

Child
Grandchild

Is this person a beneficiary? *

Does this person share your address?

Full Name *

First

Middle

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child/Grandchild 6

Child
Grandchild

Is this person a beneficiary? *

Does this person share your address?

Full Name *

First

Middle

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Legal/Financial/Estate Contacts

Please select any of the following that you utilize:

Attorney
Accountant
Tax Preparer
Investment Professional
Insurance Agent
Estate Executor
Successor Trustee
Power of Attorney
Guardian(s) for Children
Prearranged Funeral/Burial

Attorney

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Accountant

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Tax Preparer

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Investment Professional

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Agent

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Estate Executor

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Successor Trustee

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Power of Attorney

Firm/Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Guardian(s) for Children

Name(s)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Prearranged Funeral/Burial

Funeral Home Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Financial Portfolio

Income Sources

Please select any of the following that you receive:

Employment Income
Investment Income
Social Security
Pension
Other

Please approximate if you are unsure of the exact amount.

Employment Income Amount

Employment Income Frequency

Investment Income Amount

Investment Income Frequency

Social Security Amount

Social Security Frequency

Pension Amount

Pension Frequency

If Other, please describe. Include amount and if received monthly or annually:

Expenses

Please select any of the following that you pay for regularly:

Mortgage
Utilities
Insurance
Prescriptions
Internet/Cable
Cell Phone
Credit Cards
Food
Entertainment
Other

Please approximate if you are unsure of the exact amount.

Mortgage Payment Amount

Mortgage Payment Frequency

Utility Payments Amount

Utility Payments Frequency

Insurance Payment Amount

Insurance Payment Frequency

Prescription Payments Amount

Prescription Payments Frequency

Internet/Cable Payment Amount

Internet/Cable Payment Frequency

Cell Phone Payment Amount

Cell Phone Payment Frequency

Credit Card Payments Amount

Credit Card Payments Frequency

Food Cost

Food Cost Frequency

Entertainment Costs

Entertainment Costs Frequency

If Other, please describe. Include amount and if paid monthly or annually:

Short-Term Reserves

Please select any of the following that you utilize:

Checking
Savings
Money Market Funds
Certificates of Deposit

Number of Checking Accounts

Institution

Account Number

Institution

Account Number

Institution

Account Number

Institution

Account Number

Number of Savings Accounts

Institution

Account Number

Institution

Account Number

Institution

Account Number

Institution

Account Number

Money Market Fund Institution

Certificates of Deposit Institution

Investments

Please select any of the following that you utilize:

Brokerage
Mutual Funds
Stocks
Bonds
Corporate Stock Options

Brokerage Institution

Mutual Funds Institution

Stocks Institution

Bonds Institution

Corporate Stocks Institution

Retirement Accounts

Please select any of the following that you utilize:

Traditional IRA
Roth IRA
401(k)/403(b)/457 Plans
Profit-Sharing Plans
Pension Plans
Annuities
Other

Traditional IRA Institution

Roth Institution

401(k)/403(b)/457 Plan Institution

Profit-Sharing Plan Institution

Annuities Institution

If Other, please specify:

College Savings Plans

Please select any of the following that you utilize:

UGMA
UTMA
529 Plans

How many beneficiaries?

Beneficiary 1 *

First

Last

Beneficiary 2 *

First

Last

Beneficiary 3 *

First

Last

Beneficiary 4 *

First

Last

Personal Property

Please select any of the following that you own:

Second Home/Investment Property
Business/Partnership
Car/Truck/Boat
Private Loans

Second Home/Investment Property

Approximate Market Value

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business/Partnership

Business Name

Percent Ownership

Selected Value: 0

Address

Address Line 1

Address Line 2

City

State

Zip Code

Car/Truck/Boat

Approximate Market Value

Make/Model Information

Private Loans

Loan Amount

Interest Rate

Final Thoughts

What else would you like us to know about you, your family, or your finances?

How did you hear about us?