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 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place 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 citizen Are 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 taxes Social Security Number or TINWe will need this for any IRS communications. Do you currently have a valid USA passport?* Yes No Passport Number* Expiration Date of Passport* Month Day Year Driver License Number* Issuing State of Driver License* Expiration Date of Driver License* Month Day Year Occupation* Politically Exposed Person*Are you or any members of your immediate family a politically exposed person or PEP? Yes No Legal Issues*Have you or any legal person of which you have been an officer, director, shareholder, manager, member, authorized person, founder, or council member been involved in any court proceedings, litigation, or been declared bankrupt or insolvent - past, current, or pending? Yes No Criminal Conduct*Have you ever been indicted or convicted of any criminal offense or offenses that constitute financial misconduct? Yes No Further Information*If you answered YES to any of the previous three 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 WealthPlease provide details as to the source of wealthMarital Status* Never Married Divorced Widowed Married Name of Spouse?* First Middle Last Date of MarriageMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number 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. CommentsThis field is for validation purposes and should be left unchanged. Δ