Highlighted Areas Are "FINRA/Compliance Required Data" |
Personal Information |
Do you have a spouce?
Yes
No |
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CLIENT |
SPOUSE |
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LAST NAME |
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Do you have a: |
FIRST NAME/MIDDLE NAME |
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Will?
Power of Attorney?
Trust?
Estate Plan?
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ADDRESS |
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DATE OF BIRTH |
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SOCIAL SECURITY NUMBER |
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Phone No |
Drivers License Number |
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Home :
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State Issued |
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Work :
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Issue Date / Exp Date |
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Cellular:
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Occupation |
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Employer |
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Employer Address |
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Est. Retirement Age |
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E-Mail Address |
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Dependents |
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NAME |
Date of Birth |
Relationship |
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Beneficiary Info (Please check below) |
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NAME |
DOB |
Social Security Number |
% Allocated |
Primary |
Contingent |
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Primary |
Contingent |
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Primary |
Contingent |
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Assets |
Income Categories |
Specifics |
Estimated Monthly Income |
Estimated Annual Income |
Work |
Employer |
$
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$
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Employer (spouse) |
$
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$
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$
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Personal Savings and Investments |
Savings |
$
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$
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Checking |
$
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$
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Other (Money Mkt, CD's, etc.) |
$
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$
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$
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Roth IRA |
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$
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$
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$
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$
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$
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IRA, SEP, Other |
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$
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$
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$
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$
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$
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Oualified ERISA |
401k |
$
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$
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Oualified ERISA |
403b |
$
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$
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Pension |
$
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$
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Pension |
$
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$
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Monthly Total |
$
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$
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$
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Social Security |
Client |
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$
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Spouse |
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$
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$
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Other Income |
Rental Income, Inheritance, etc. |
$
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Expenses |
Expense Categories |
Specifics |
Current Monthly Amount |
Total Annual Amount |
Home |
Mortgage / Rent |
$
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$
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Interest Rate % |
Years Remaining |
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Property Taxes |
$
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$
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Utilities (power, heat, water) |
$
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$
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Sub total |
$
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Current Value |
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Essentials |
Food / Groceries |
$
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$
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Medical Bills |
$
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$
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Medicine |
$
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$
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Vehicle Loan Payments |
$
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$
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Fuel |
$
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$
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Childcare |
$
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$
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Subtotal |
$
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Insurance |
Life Insurance |
$
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$
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Long Term Care |
$
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$
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Medical |
$
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$
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Vehicle |
$
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$
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Homeowner / Rental |
$
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$
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Disability |
$
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$
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Subtotal |
$
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Debt |
Credit Cards |
$
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$
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Loans |
$
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$
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Subtotal |
$
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Taxes
Bracket %
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Federal |
$
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$
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State |
$
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$
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Local |
$
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$
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Sub Total |
$
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Income Taxes: Income Taxes: If
we do not prepare your tax returns,
please provide a copy of your most
recent return for us to review. |
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Additional financial information and expenses |
What are your other investments (includes other assets held by LPL)? Please indicate percentage of net worth (must equal 100%) |
Real Estate |
% |
Mutual Funds |
% |
Insurance |
% |
Checking |
% |
Savings |
% |
Annuities |
% |
Equities |
% |
Bonds |
% |
Alternative Investments |
% |
Other |
% |
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If other, please explain |
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What is your investment time horizon for this account? |
One to three years |
Three to five years |
Five to 10 years |
More than 10 years |
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Do you have liquidity needs from the funds in this account? |
Yes |
NO |
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If yes, when do you need these funds? |
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Zero to three years |
Zero to three years |
If yes, specify the approximate dollar amount for the time range indicated above. |
$
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Client Signature |
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Date : |
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Received by: |
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JFR Financial Services, Inc. on |
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Per FINRA Rules 2111 and 2090: All highlighted areas are mandatory. Other sections are used by us
to develop your plans, but not required to meet FINRA compliance requirements. |
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Investment Risk Tolerance (1 = low; 10 = high) :
1
2
3
4
5
6
7
8
9
10 |
Do you have any addtional comments about your finances? |
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I/We reviewed each question/section and provided answers to the best of my/our ability. I understand that any recommendations made
assume the information I provided herein is accurate. |
Client Signature : |
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Date : |
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Securities offered through LPL Financial, Member FINRA/SIPC. Investment advice offered through JFR Financial Services, Inc., a registered Investment Advisor and separate entity from LPL Financial.