CORNERSTONE FINANCIAL SERVICES, INC N. Lynnhaven Road, Suite 100 Virginia Beach, VA Tel: Fax:

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2 CORNERSTONE FINANCIAL SERVICES, INC N. Lynnhaven Road, Suite 100 Virginia Beach, VA Tel: Fax: Section I: Client Data Sheet Full Name: Last First Middle DOB: / / Place of Birth: SSN: - - Driver s License Number: State/Country: Issued: Expires: U.S. Citizen? Yes No. If no, where? : Home Address: Work Address: Employer: Job Title: Home Phone: Cellphone: Work Phone: Number of years employed: Approximate Annual Income: Marital Status: Married Single Widowed Divorced Separated If Divorced, please explain any divorce obligations such as child support, alimony, or life insurance: If Widowed, date and place of death of deceased spouse: Full Name of Client 2 or Spouse: Last First Middle DOB: / / Place of Birth: SSN: - - Driver s License Number: State/Country: Issued: Expires: U.S. Citizen? Yes No. If no, please explain: Client 2 Work Address: Employer: Job Title: Cellphone: Work Phone: Number of years employed: Approximate Annual Income: 2

3 Section II: Family/Beneficiary Information Client 1 Parents: Father s Name: Still Living? DOB: / / Mother s Name: Still Living? DOB: / / Client 2 Parents: Father s Name: Still Living? Mother s Name: Still Living? DOB: / / DOB: / / Children: Name: DOB: / / Address: Name: DOB: / / Address: Section III: Background Information Are there special needs for any child? Do you support or expect to support anyone else such as a parent or other person? Have you ever served in the Military? (Branch, Rank, Serial #, Dates) Have you ever lived in a Community Property State? (AZ, CA, TX, ID, LA, NM, NV, WA & WI) Previous Residences (States): Do you or your spouse have any Wills, Trust Agreements, or other Estate Planning documents, or have you had any of these documents prepared for you? If YES please give detail (attorney who drafted, date, etc.) Have you or your spouse made any gifts after 1982 in excess of $10,000? Yes No Do you want to forgive any loans at death? Yes No Do you have specific instructions for your burial? Yes No Do you anticipate receiving an Inheritance? Yes No Have you received an Inheritance recently? Yes No If you answered YES to any of the above questions, please explain: In the following, please indicate Name, Telephone Number and Relationship to you for each individual. Executors of Wills: Trustees of Trusts, etc.: Guardians for Children: Power of Attorney (General): Power of Attorney (Medical): 3

4 Section IV: Inventory of Assets (Title: J-Joint, H-Husband, W-Wife, TC-Tenants in Common, C-Community Property, and P-Partial Interest) DEPOSIT ACCOUNTS: (i.e. checking, savings, money market, CDs, etc.) Description Title Financial Institution Account Balance Sample: Checking Joint Bank of America $3,000 Total $ REAL ESTATE: Description Location Title Sample: Residence Virginia Beach Joint entirety Date Acquired Original Cost Current Fair Value Loan Amount/Term 1998 $400,000 $450, yr fixed at 5% Total $ $ MARKETABLE SECURITIES: (i.e. Stocks, Bonds, Brokerage Accounts, 401(k), IRAs) Description / Custodian Registration Acquired Cost Beneficiary Current Fair Value Additions mo/ yr Sample: Bryan/American Funds Roth IRA 1998 $10,000 Spouse $50,000 $5,000/Yr. Total $ $ 4

5 LIABILITIES/DEBTS: Description / Type / Rate Title Year Acquired Balance Due Monthly Payment Rate/ Percent Sample: Chase Credit Card JT 2002 $1,500 $1,500 2% LIFE INSURANCE: (Type: T-Term, WL-Whole Life, G-Group Term, V-Variable, VUL-Variable Universal Life) Description (Type) Owner Insured Beneficiary Acquired Premium mo/yr Cash Value Death Benefit Sample: WL Bryan Rex Bryan Rex Jerry Rex 2001 $550/mo $10,000 $1,000,000 Total $ $ OTHER INSURANCE (Disability, Long Term Care, etc) Description (Type) Owner Company Benefit Description Sample: LTC Bryan Rex Unum $150/ day 6 year benefit EXPECTED RETIREMENT INCOME: What do you hope retirement will look like? At what age do you plan to retire? At what age does your spouse plan to retire? Do you plan to live in a different state during retirement? If yes, what state? Description (Type) Owner Amt per Month Starting Retirement Year Continuing Amount for Spouse Ex: Social Security Husband $1, Ex: Pension Wife $ $350 5

6 Section V: Risk Tolerance Answer the following questions by circling one number to determine your risk tolerance: 1. How important is capital preservation? 2. How important is growth? 3. How important is low volatility? 4. How important is inflation protection? 5. How important is current cash flow? 6. How much risk are you willing to take to achieve a higher return? Section VI: Other Advisors Accountant/CPA: Attorney: Stockbroker: Financial Planner: Insurance Agent: Trust Officer: Physician: 2940 N. Lynnhaven Road, Suite 100 Virginia Beach, VA FAX: INVEST Financial Corporation (INVEST), member FINRA/SIPC, and its affiliated insurance agencies offer securities, advisory services and certain insurance products and are affiliated with Cornerstone Financial Services. INVEST does not offer tax or legal advice. 6

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