The Wealth Preservation Institute

Include as much data as possible to help us create the most accurate scenarios for your planning needs.

	Client Intake Form
What we need for Initial Planning	Client 1	Client 2
Personal Details
Marriage Status	SingleMarried
Name
Birthdate
Where Were You Born
		Address is the Same as Client #1
Home Address
City, State, Zip	, ,	, ,
Primary Residence
# of Yrs. At This Address
Home Phone
Cell Phone
Preferred Email
Social Security Number
Drivers License Number, Issue Date & Expiration	, ,	, ,
Marriage Status
Anniversary Date
Preferred Method of Communication	EmailPhoneText	EmailPhoneText
Social Media Usage	FacebookTwitterLinked In	FacebookTwitterLinked In
Children's full names, DOB	,	,
Financial Information
Checking
Savings
Money Market
CDs
Treasuries
Fixed Indexed Annuities
Cash Value / Whole Life Ins.
Cash Value Variable Life Ins.
Variable Annuities
Insurance
Do you have any Permanent Insurance - (Whole Life, IUL, VUL, UL)	YesNo CarrierDate IssuedCash ValueDeath Benefit	YesNo CarrierDate IssuedCash ValueDeath Benefit
Do you have any Term Insurance?	YesNo CarrierYear IssuedPremiumDeath Benefit	YesNo CarrierYear IssuedPremiumDeath Benefit
Do you have any annuities?	YesNo SoNeed to know the carrierYear IssuedAccount Balance	YesNo SoNeed to know the carrierYear IssuedAccount Balance
Qualified Plans	Balance Info	Balance Info
401k
IRA
403B
SEP
ROTH IRA
Non-Qualified	Balance Info	Balance Info
Stocks
Bonds
Mutual Funds
ETF
REIT
Comodities
Options
Real Estate
529 Plan
Other
Can you take an inservice distribution from your 401k? (Check with your company plan administrator if unsure)
Expenses
Total Current Monthly Gross Household Expenses
Income
Name of Employer
Yrs. With Employer
Industry
Anticipated Social Security
Pension
Tax Free
Other
Other Info
Have Estate Plan	YesNo	YesNo
Need to be reviewed	YesNo	YesNo
Name of your tax preparer
What we will need if we decide to work together:
Social Security Number
Drivers License Number, Issue Date & Expiration	, ,	, ,
Please list Beneficiary Info:
Name
DOB
Address
SSN
% Beneficiary
Please list Beneficiary Info (Optional):
Name
DOB
Address
SSN
% Beneficiary
Please list Beneficiary Info (Optional):
Name
DOB
Address
SSN
% Beneficiary
Please list Beneficiary Info (Optional):
Name
DOB
Address
SSN
% Beneficiary