Yes No Are You a Politically Exposed Foreign Person (PEFP)?

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1 1. OWNERSHIP INFORMATION Mr. Mrs. Miss. Dr. Company Initials of Birth: Social Insurance Number: - - Civic Address City Province Postal Code ( ) - ( ) - Phone # Cell Phone # Address Driver License #: Expiry : Are you a U.S. Resident for Tax Purpose? Yes No Are you a Politically Exposed Foreign Person (PEFP)? Yes No Name of Employer Business Type Occupation (specific) Years of Employment Is Occupation Cash Intensive? Yes No Do you have pension plan? Yes No 2. SPOUSAL INFORMATION Mr. Mrs. Miss. Dr. Company Initials of Birth: Social Insurance Number: - - Civic Address City Province Postal Code ( ) - ( ) - Phone # Cell Phone # Address Driver License #: Expiry : Are you a U.S. Resident for Tax Purpose? Yes No Are you a Politically Exposed Foreign Person (PEFP)? Yes No Name of Employer Business Type Occupation (specific) Years of Employment Is Occupation Cash Intensive? Yes No Do you have pension plan? Yes No 1

2 3. DEPENDENTS INFORMATION 1) of Birth: Male Female 2) of Birth: Male Female 3) of Birth: Male Female 4. INVESTMENT BACKGROUND Do you presently own individual stocks? Yes No Have you owned stocks in the past? Yes No Have you previously held mutual fund? Yes No If Yes, how many years do you own the mutual fund? Investment Experience: Nil Some Extensive Investment Knowledge: Poor Fair Good Very Good Sophisticated Investment Objective Risk Tolerance Intended Use Time Horizon Liquidity % Income % Long-Term % Very Low % Low % Low to Moderate % Moderate % Moderate to High % High % Retirement Savings Guaranteed Income Children s Education Income Generation Corporation Invest Other 1-5 Years 6-9 Years Years Lifetime 5. FINANCIAL ANALYSIS Monthly Income Statement (Employment, Pension, Investment): Annual Monthly Gross Monthly Net Self $ $ $ Spouse $ $ $ Other Income $ $ $ Total $ $ $ Monthly Debt Payments: Regular Savings Loan/Debt Payment Mortgage (principal & Interest) Self $ $ $ Spouse $ $ $ Total $ $ $ 2

3 Assets: RRSP S Plan Type Amount Institution Open-Non Registered Plan Type (Individual/Joint) Amount Institution Tax Free Saving Accounts Amount Invested Market Value Institution Pensions Plan Type Amount Institution Real Estate: Property Description Market Value Mortgage Amount Institution Renewal Is your mortgage insured? Yes No Loan/Lines of Credit: Amount Owing Interest Rate Institution Credit Cards: Amount Owning Interest Rate Credit Card Company 3

4 6. WILLS & POWER OF ATTORNEY Advisors: Lawyer Accountant Name of Executor Power of Attorney Do you have a will? Yes No Completed Power of Attorney for Property Yes No Completed Power of Attorney for Personal Care Yes No Completed Notes: 7. LIFE INSURANCE BACKGROUND Life insurance policies: Name of Insured Type of Coverage Benefit Amount Insurance Company Disability Coverage: Critical Illness Coverage: Long-term Care Coverage: 4

5 Group Insurance Coverage: Group Plan Number Benefit Benefit Amount Insurance Company 8. CLIENT INFORMATION REQUEST Below is a list of information we require you to /Mail to us. Any personal information disclosed to FFG is held in the strictest of confidence. Required Information: 1) Originals of any personal insurance policies (mortgages, life, car, home disability) Yes No 2) RRSP contribution limits (Your most recent Revenue Canada Assessment Form) Yes No 3) Tax Free Savings Accounts Statements Yes No 4) Employment retirement package and group benefit plans Yes No 5) Personal RRSP Statements (Individual Plans and Spousal RRSP Plans) Yes No 6) Non-registered Assets (including GIC investments, bonds, savings accounts) Yes No 7) Major Credit Liabilities (Credit Cards, Loans, Credit Lines, ect. ) Yes No 8) Wills and Powers of Attorney Yes No 9. FOR CHARITABLE ORGANIZATIONS Not for Profit Account? Yes No If yes, is it a Registered Charity? Yes No If yes, is it a Soliciting Public Fund? Yes No 10. DISCLOSURE AND SIGNATURE AML Risk Rating? Low Medium High Are there any conflicts of interest with this client? Yes No If yes, specify Will any other person has control of these contracts (including POA)? Yes No If yes, specify Will any other person have a financial interest in these contracts? Yes No If yes, specify Client Signature Joint Client Signature Representative Signature 5