Confidential Information Collection Form

Client Names: ______Date of Completion: ______

Victoria J. Roberson, Esq. [email protected] 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)

Spouse Birthdate: ______(First) (Middle) (Last)

Home Address:

County/City of Residence: Home Phone:

Email Address ______Spouse’s Email ______Cell Phone ______Spouse’s Cell Phone ______Employer Spouse’s Employer Work Phone Spouse’s Work Phone Position Spouse’s Position

Children (Name) Birthdate Marital Phone Address Status (if different than your home) 1. 2. 3. 4.

Other Dependents (Name) Age Relation Address (if different than your home) 1. 2. 1

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 Type of Business greater than 5% of any (C Corp/S Corp/ Business Name Percent Interest business? Partnership/LLC) Self: (Y/N) ______

Spouse: (Y/N) ______

2 Real Estate

Ownership Property Type Address Value Mortgage You Spouse Joint Home

Vacation

Bank Accounts

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

3 Stock/Brokerage Accounts

Account Type Company Value (Stocks/Bonds) Spouse Joint

Retirement Accounts

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

4 Life Insurance

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

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

5 # Question Yes No # Question Yes No Have you and your spouse ever lived in a Do you or your 1. community property state - Arizona, California, 9. spouse Idaho, Louisiana, New Mexico, Nevada, Texas, anticipate any Washington or Wisconsin? ☐ ☐ other significant ☐ ☐ change in your assets, liabilities or income in the next few years?

2. Are you or your spouse a citizen of a country 10. Do you or your other than the United States? ☐ ☐ spouse own any ☐ ☐ insurance on the life of another person?

3. Do you or your spouse own real estate outside of 11. Are you, your Virginia? ☐ ☐ spouse or any ☐ ☐ family member a grantor, beneficiary or trustee of any existing trust?

4. Do you or your spouse own any partnership 12. Are you or your interests? ☐ ☐ spouse a party ☐ ☐ to a pre-marital, post-marital, separation or property settlement agreement?

5. Have you or your spouse made gifts in excess of 13. Are you, your $10,000 in value to any one person in any year ☐ ☐ spouse or any ☐ ☐ after 1981? of your children adopted or from a previous marriage?

6. Are you or your spouse interested in making 14. Do you, your charitable gifts at death? ☐ ☐ spouse or any ☐ ☐ family member have any serious health problems or disabilities?

7. Have you or your spouse received any 15. Do you or your substantial gifts or inheritances? ☐ ☐ spouse have ☐ ☐ special requests regarding funeral, burial or cremation, or donation of body organs?

8. Do you or your spouse expect to receive any 16. Do you or your substantial gifts or inheritances? ☐ ☐ spouse have ☐ ☐ “living wills” or health care powers of attorney? 6