First Name *

Last Name *

Date of birth *

Phone *

Email *

State *

(These States ONLY) AZ, CA, FL, GA, HI, ME, MI, NC, TX, IL

What specific problem are you looking to solve today *

Ex. Asset Protection, Higher Interest/Return on Investment, Tax Strategies, Retirement, Rollover, etc.

What is your current return on investments *

Ex. 4%, 6%, 8%, etc.

Existing Assets *

Ex. Stocks/Bonds, Life Insurance, Annuity, IRA, Cash, etc.

Investable Assets *

Ex. $500k-$750k, $750k-$1M, $1M+

Account Assets will come from *

Ex. Checking and/or Savings account, Investment account, IRA, 401k, 1035 exchange, etc

What financial obligations or debts do you have *

Ex. Credit Cards, Mortgage, Bank Loans, No debt, etc.

Current Financial Advisor *

Ex. Yes or No

Current Financial Advisor 2 *

Ex. N/A-If no adviser currently, Schwab, Fidelity, Morgan Stanley, Merrill Lynch, etc.

How soon are you looking to get started? (If we find a product that solves the challenges you are currently facing) *

Ex. Now/Today, Within 30 Days, 3 Months, etc.

Is there anyone else helping you make the decision to move forward *

Ex. Sole Decision Maker, Spouse, Financial Advisor, Child, Friend, etc.

Who will be your beneficiary *

Ex. Spouse, Children, Relative, Charity, etc.

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