Confidential Information Collection Form

Client Name: ______

Date of Completion: ______

Victoria J. Roberson, Esq.

Direct Dial: 804-893-4065

301 Southlake Boulevard, Suite 102/North Chesterfield, Virginia 23236/Office: (804) 893-3000

Fax: (804) 464-2050

Personal Information

Name / Birthdate: ______
(First) / (Middle) / (Last)
Home Address:
County/City of Residence:
Primary/Home Phone:

Email Address______

Cell Phone______

Employer
Work Phone
Position
Children (Name) / Birthdate / Marital
Status / Phone / Address
(if different than your home)
1.
2.
3.
4.
Other Dependents (Name) / Age / Relation / Address
(if different than your home)
1.
2.

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Financial Advisors

Advisor / Name / Company / Phone Number
Accountant/CPA
Financial Planner
Life Insurance Agent
Investment Advisor
Trust Officer
Other Advisor(s)

Business Interests

Do you or your spouse own greater than 5% of any business? / Type of Business
(C Corp/S Corp/
Partnership/LLC) / Business Name / Percent Interest
Self: (Y/N) ______
Spouse: (Y/N) ______

2

Real Estate

Property Type / Address / Value / Mortgage / Ownership
You / Spouse / Joint
Home
Vacation
Other

Bank Accounts

Account Type
(Checking/Savings) / Company / Value / Ownership / Pay on Death Designation
You / Spouse / Joint

3

Stock/Brokerage Accounts

Account Type
(Stocks/Bonds) / Company / Value / Ownership / Transfer on Death Designation
You / Spouse / Joint

Retirement Accounts

Account Type
(IRA/401(k)/Annuity) / Company / Value / Ownership / Beneficiary
You / Spouse / Joint

4

Life Insurance

Owner / Insured / Company / Type
(Term/Permanent/Group) / Face Amount / Beneficiary

Please use additional sheets if necessary, or you may have your financial advisor forward your financial summary to us directly.

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# / Question / Yes / No / # / Question / Yes / No
1. / Have you ever lived in a community property state - Arizona, California, Idaho, Louisiana, New Mexico, Nevada, Texas, Washington or Wisconsin while married? / ☐ / ☐ / 9. / Do you anticipate any other significant change in your assets, liabilities or income in the next few years? / ☐ / ☐
2. / Are you a citizen of a country other than the United States? / ☐ / ☐ / 10. / Do you own any insurance on the life of another person? / ☐ / ☐
3. / Do you own real estate outside of Virginia? / ☐ / ☐ / 11. / Are you or any family member a grantor, beneficiary or trustee of any existing trust? / ☐ / ☐
4. / Do you own any partnership interests? / ☐ / ☐ / 12. / Are you a party to a pre-marital, post-marital, separation or property settlement agreement? / ☐ / ☐
5. / Have you made gifts in excess of $10,000 in value to any one person in any year after 1981? / ☐ / ☐ / 13. / Are youor any of your children adopted or from a previous marriage? / ☐ / ☐
6. / Are you interested in making charitable gifts at death? / ☐ / ☐ / 14. / Do youor any family member have any serious health problems or disabilities? / ☐ / ☐
7. / Have you received any substantial gifts or inheritances? / ☐ / ☐ / 15. / Do you have special requests regarding funeral, burial or cremation, or donation of body organs? / ☐ / ☐
8. / Do you expect to receive any substantial gifts or inheritances? / ☐ / ☐ / 16. / Do you have “living wills” or health care powers of attorney? / ☐ / ☐

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