<p> Confidential Information Collection Form</p><p>Client Names: ______Date of Completion: ______</p><p>Victoria J. Roberson, Esq. [email protected] Direct Dial: 804-893-4065</p><p>301 Southlake Boulevard, Suite 102/North Chesterfield, Virginia 23236/Office: (804) 893-3000 Fax: (804) 464-2050 Personal Information</p><p>Name Birthdate: ______(First) (Middle) (Last)</p><p>Spouse Birthdate: ______(First) (Middle) (Last)</p><p>Home Address:</p><p>County/City of Residence: Home Phone: </p><p>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</p><p>Children (Name) Birthdate Marital Phone Address Status (if different than your home) 1. 2. 3. 4.</p><p>Other Dependents (Name) Age Relation Address (if different than your home) 1. 2. 1</p><p>Financial Advisors Advisor Name Company Phone Number Accountant/CPA</p><p>Financial Planner</p><p>Life Insurance Agent</p><p>Investment Advisor</p><p>Trust Officer</p><p>Other Advisor(s)</p><p>Business Interests</p><p>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) ______</p><p>Spouse: (Y/N) ______</p><p>2 Real Estate</p><p>Ownership Property Type Address Value Mortgage You Spouse Joint Home</p><p>Vacation</p><p>Other</p><p>Bank Accounts</p><p>Account Type Company Value Pay on Death Designation (Checking/Savings) Spouse Joint</p><p>3 Stock/Brokerage Accounts</p><p>Account Type Company Value (Stocks/Bonds) Spouse Joint</p><p>Retirement Accounts</p><p>Account Type Company Value Ownership Beneficiary (IRA/401(k)/Annuity) You Spouse Joint</p><p>4 Life Insurance</p><p>Owner Insured Company Type Face Beneficiary (Term/Permanent/Group) Amount</p><p>Please use additional sheets if necessary, or you may have your financial advisor forward your financial summary to us directly.</p><p>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?</p><p>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?</p><p>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?</p><p>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?</p><p>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?</p><p>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?</p><p>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?</p><p>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</p>