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Confidential Fact Finder Form

Please complete the following form or call us at 716-877-7079.
Toll free number at 1-800-652-5522.

Client Information

Name: Date of Birth:
Address:            M/F:
City: State: Zip:
Phone:    Fax:
Email:     Soc Sec #
US Citizen or Perm. Resident: Y/N if no Visa type:

Employer Planned Retirement Date
or if retired, date retired Anniversary Date

Spouse Information

Name: Date of Birth:
Address:            M/F:
City: State: Zip:
Phone:    Fax:
Email:     Soc Sec #
US Citizen or Perm. Resident: Y/N if no Visa type:

Employer Planned Retirement Date
or if retired, date retired Anniversary Date

Children, Please Include Names & Date of Birth:

What are your primary financial concerns:

Do you have a current will? Yes No
Living Trust? Yes No
Are you concerned about possible nursing home expenses? Yes No

Household Cash Flow
Income: /Yr. Source:
Income: /Yr. Source:
What are you approximate annual expenses? (click for Budget Analysis Worksheet)

Amounts in Banks, Savings & Loans & Credit Unions (Non-IRA)
(Checking, Savings, Money Markets, CD's, Etc.)

	Name of Institution	Type of Account	Maturity Date	Interest Rate	Approximate Balance
1.				%
2.				%
3.				%
4.				%
5.				%

IRA Accounts and Other Retirement Accounts
Please Bring in Your Latest Reports/Statements

	Account Type & Location (Bank, Broker, Employer, Etc.)	Type (401k, IRA, TSA, Etc.)	Approximate Market Value
1.
2.
3.
4.
5.

Stocks & Bonds
(Where you hold the Certificates Yourself)

	Name of Stock/Bond	# of Shares	Approximate Market Value
1.
2.
3.

Life Insurance
(Please Bring in Policies & Latest Statements)

	Company	Insured	Type (whole or Term)	Approx. Death Benefit	Cash Value
1.
2.
3.

Residence & Other Real Estate Owned

	Property Address	Original Cost	Approx. Value	Debt	Net Cash Flow (if a rental)
1.
2.
3.

Other Assets

1.
2.
3.
4.

Mutual Funds and/or Brokerage Accounts
(Please bring in your latest reports/statements)

	Name of Brokerage Firm/Mutual Fund	# of Shares	Approximate Market Value
1.
2.
3.
4.
5.
6
7.

Annuities
(Fixed or Variable)

	Company	Annuitant Owner	Date Purch.	Interest Rate	Approximate Value
1.				%
2.				%
3.				%
4.				%
5.				%

Disability Insurance
(Please bring in policies & latest Statements)

	Company	Insured	Benefit Period	Monthly Benefit	Premium
1.
Other Benefits FIO Date:
2.
Other Benefits FIO Date:
3.
Other Benefits FIO Date:

All requested information is kept in the strictest of confidence.
No information will be released without your authorization.

	Financial Services, Inc.	Specializing in Insurance and Retirement Plans for Physicians, Dentists and Health Care Professionals
	Strategies For Financial Health