Please complete this form. You'll need your passport or driver license information to complete the form. All information provided is strictly confidential. Legal Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Suffix Prefer to be called: Preferred Name Sex*Please choose what is listed on your passport (or driver license if no passport)Please select from drop-downMaleFemaleResidential Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Length of time at current address*How long have you lived there?County (NOT country)*In which COUNTY is your address located?Is your mailing address the same as your residential address?* Yes No Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Home/Cell Phone*Work PhoneOther PhoneDate of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of Birth (City/Town/Village)*Country of Birth*US Citizen?* Yes No If no, what nationality?*Are you a US resident alien?* Yes No Are you a citizen of any other countries?* Yes No Other citizenships*Please list the countries of which you are a citizenAre you a tax resident of any other countries?*Do you pay taxes in other countries? Yes No Other tax residency*Please list the countries where you pay taxesSocial Security Number or TINWe will need this for any IRS communications. show Social Security Number or TINDo you currently have a valid USA passport?* Yes No Passport Number* show Passport NumberExpiration Date of Passport* Month Day Year Driver License Number* show Driver License NumberIssuing State of Driver License*Expiration Date of Driver License* Month Day Year Occupation*Employment History*Employment History - for last 3 positions (please include company name and website.)Where can we see you online?Please list any professional websites or social media pages which feature your personal profile.Politically Exposed Person*Are you or any members of your immediate family a politically exposed person or PEP? Politically Exposed Person (PEP) includes the following: head of state; politician; government official; senior judicial or military official; foreign diplomat; honorary consul; senior executive of state-owned enterprise; an immediate family member of any of the above; and a close associate of any of the above, including any person in a close business relationship or any person in a position to conduct substantial financial transactions on behalf of any of the above. Yes No Refused entry to a foreign country*Have you ever been refused entry to a foreign country? Yes No Bankruptcy*Have you personally, or any entity or legal arrangement of which you have been an officer, director, or a shareholder, ever been adjudicated bankrupt by a Court in any jurisdiction? Yes No Entity Crimes*Have you or any company of which you have been an officer, director, or a shareholder, ever been convicted of any crime (including a financial crime), indicted, or are you or have you been the subject of any investigation or been interviewed in connection with any investigation by bodies such as the SEC, IRS, FBI or any other federal or state law enforcement or regulatory body or any foreign government or agency? Yes No Entity Investigation*Is any legal entity or legal arrangement, of which you are a director, shareholder, manager, trustee, officer or controller currently the subject of a formal enquiry, investigation or disciplinary process by a governmental, professional or regulatory body? Yes No Criminal Conduct*Have you ever been indicted or convicted of any criminal offense or offenses that constitute financial misconduct? Yes No Censure/Discipline*Have you ever been censured or disciplined by any licensing or regulatory authority, had a professional license suspended or revoked, or been subject to a Cease and Desist Order? Yes No Litigation*Are you or have you been declared bankrupt or insolvent or involved in any court proceedings or litigation, whether past, current or impending? Yes No Further Information*If you answered YES to any of the previous eight questions, please provide further detailsSource of Wealth*Please indicate the source(s) of wealth or business that will be transferred into your trust or LLC Inheritance Business Income Employment (e.g. salary, wages, bonus, etc.) Gifts Loan Sale of Shares Sale of property Other (please provide details below) Other Source of Wealth*Please provide details as to the source of wealthNet worth*Declare your estimated net worth - nearest USD$MAsset Holdings*Describe your significant asset holdings and where they are locatedLocation of activities*Describe the geographical location of your business/investment activitiesMarital Status* Never Married Divorced Widowed Married Name of Spouse?* First Middle Last Date of MarriageMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number of dependentsFamilyDo you have children?* Yes No Children's Names and Ages*Add additional children by clicking the "+" icon to the rightFirst NameLast NameDate of Birth Do you have an existing Will? Yes No Have you ever executed a trust (either revocable or irrevocable)? Yes No Have you ever filed a Federal Gift Tax Return? Yes No Do you have an existing General Power of Attorney? Yes No Thank you for completing this worksheet! Be sure to click the Submit button below and look for the green checkmark for success. If you don't see the green checkmark, please review the worksheet for any missing fields. Missing fields will be highlighted in red. NameThis field is for validation purposes and should be left unchanged. Δ
