Corvus Capital LLC



Customer Focused QuestionnaireGeneral InformationClient’s Name ______________________________________________________________________________Address______________________________________________________________________________Email Address______________________________________________________________________________TelephoneHome: _______________ Work: _______________ Cell: _______________ Fax: _____________Date of Birth___/___/______Social Security # _____________________________________________Employer __________________________________________________ Annual Income _______________Spouse’s Name _______________________________________________________________________________Email Address ______________________________________________________________________________TelephoneHome: ______________ Work: ________________ Cell: _______________ Fax: _____________Date of Birth___/___/______Social Security # _____________________________________________Employer __________________________________________________ Annual Income _______________Total Net Worth ________________________ Income from Investments _____________________________Number of Children/Dependents ____________Name ________________________ DOB ____/____/______ Educational Savings _____________________Name ________________________ DOB ____/____/______ Educational Savings _____________________Name ________________________ DOB ____/____/______ Educational Savings _____________________Name ________________________ DOB ____/____/______ Educational Savings _____________________Number of Grandchildren _______________Do you currently have educational savings for a grandchild or grandchildren? ____________________________What are your top three financial goals?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current Holdings__________ ___Client____________Spouse___________Joint___________Primary Residence$ _______________$ ______________ $ _______________Secondary Residence$ _______________$ ______________ $ _______________Other Real Estate$ _______________$ ______________$ _______________Cash & CD’s$ _______________$ ______________ $ _______________Bonds (Taxable)$ _______________$ ______________ $ _______________Bonds (Muni)$ _______________$ ______________ $ _______________Stocks$ _______________$ ______________ $ _______________Mutual Funds$ _______________$ ______________ $ _______________Annuities (Variable)$ _______________$ ______________ $ _______________Annuities (Fixed)$ _______________$ ______________ $ _______________Qualified Assets:$ _______________$ ______________ $ _______________IRA’s$ _______________$ ______________$ _______________401K’s$ _______________$ ______________ $ _______________Business Interests$ _______________$ ______________ $ _______________Other (Account Type)__________________$ _______________$ ______________ $ _________________________________$ _______________$ ______________ $ _________________________________$ _______________$ ______________ $ _______________Current DebtMortgage$______________ Rate _____% Term __________ Pay-Off ____________Auto(s)$______________ Rate _____% Term __________ Pay-Off ____________Credit Card(s)$______________ Rate _____% Term __________ Pay-Off ____________Home Equity$______________ Rate _____% Term __________ Pay-Off ____________Retirement CalculationsAt what age would you like to retire? _________________ At what age would your spouse like to retire? _________________Total monthly amount from other income:Social Security______________Pension ______________Other______________Insurance1. Long Term CareName of Insured _________________________________ Company _________________________________Benefit Amount _______________ Premium __________ Inflation Protection ________________________2. DisabilityName of Insured _________________________________ Company _________________________________Monthly Benefit _________________________________ Premium _________________________________3. LifeName of Insured _________________________________ Company _________________________________Cash Value ___________________ Premium ___________ Face Amount _____________________________Estate PlanningWillYes ___ No ___Date Est. ___/___/_____Power of AttorneyYes ___ No ___Date Est. ___/___/_____Living TrustYes ___ No ___Date Est. ___/___/_____Current Trustee __________________________ Successor Trustee _____________________________Are you a trustee for anyone? Yes ___ No ___Are you gifting?Yes ___ No ___If yes, please provide details below:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Professional RelationshipsCPA ______________________________________________________________________________________________Attorney __________________________________________________________________________________________Property and Casualty Agent __________________________________________________________________________Health Insurance Provider ____________________________________________________________________________Current Financial Professional _________________________________________________________________________Information Analysis (For Office Use Only)Comprehensive financial planYes ___ No ___Estate PlanYes ___ No ___PortfolioYes ___No ___CollCalcYes ___ No ___Mutual fund hyposYes ___ No ___RetCalcYes ___ No ___Ins need analysisYes ___ No ___Chris Hass, Jeff Caufield and Chad Perkins offer securities through Parkland Securities, LLC. Member FINRA/SIPC. Investment advisory representatives offer investment advisory services through Sigma Planning Corporation, a registered investment advisor. Corvus Capital, LLC is an independently owned company located at 2950 Breckenridge Lane, Suite 6, Louisville, KY 40220. Phone (502) 451-6363; Fax (502) 451-6364 ................
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