Financial 
Services, Inc
.

Specializing in Insurance and Retirement
  Plans for Physicians, Dentists
  and Health Care Professionals

Strategies For Financial Health

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

 

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


Income: /Yr.   Source:
Income: /Yr.   Source:
What are you approximate annual expenses?

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
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. 

MJB Financial Services, Inc, P.O. Box. 737, Kenmore, New York 14217
Phone: (716) 877-7079 Fax: (716) 873-8698
Outside of WNY: 1-800-652-5522
Michael J. Bruno, ChFC, CLU, RHU
Securities offered through Ensemble Financial Services, Inc.
Member NASD, SIPC 179 Sully's Trail, Pittsford, NY 14534 (585)248-0050

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