Brewer Capital Client Questionnaire Phone PERSONAL INFORMATION Legal Name SSN Date of Birth US Citizen? Yes No Drivers License # Country of Citizenship Passport # Country of Residence Home Address How long Ownership of House Own Rent City Telephone State Cell ZIP Code E-mail Marital Status Single Married Seperated No. of Dependents SPOUSE PROFILE (Spousal information IS required for married individuals, even if opening a single name account) Legal Name SSN Date of Birth US Citizen? Yes No Email Drivers License # Country of Citizenship Phone Passport # Country of Residence Address EMERGENCY INFORMATION Emergency Contact Phone Number Relationship CORPORATION INFORMATION Corporation Name Add’l Corp/501c3 Name Tax ID # Tax ID # FINANCIAL PROFILE (If Possible, please use approximate dollar values. Otherwise use letter codes found below) Net Worth Liabilities Investable Assets Banks/Financial Service/Investment Firms You Have (Had) Relationships with Firm Name Firm Name City/State City/State Account Number Account Number Personal Real Estate Net Worth Personal Real Estate Debt Property Address 1 Loan Bank/Amt Property Address 2 Loan Bank/Amt Property Address 3 Loan Bank/Amt Vehicle 1 Lease Yes No Bank/Amount Vehicle 2 Lease Yes No Bank/Amount Vehicle 3 Lease Yes No Bank/Amount Jewelry Value Add. Loan Info #1 Add. Loan Info #2 Art, Coins or other hard Assets Value? Credit Card #1 (Bank/Limit/Balance) Credit Card #2 (Bank/Limit/Balance) Amount of Loan Under $100k $100k-$250k $250k-$500k $500k-$1mm $1mm + Loan Assets/Collateral Real Estate Stocks/Bonds Vehicles Art, Jewelry, Coins Receivables, PO’s Use of Funds Debt Pay Off Acquisition Working Capital Type of Business Limited Liability Company Corporate Partnership Add’l Loan Details Desired Closing Date Liens or Judgements CURRENT INSURANCE COVERAGE CARRIER POLICY # AMOUNT DATE ISSUED PREMIUM Health Health Carrier Health Policy # Health Policy Amount Health Policy date issued Health Policy Premium Disability DisabilityCarrier Disability Policy # Disability Policy Amount Disability Policy date issued Disability Policy Premium Life life Carrier life Policy # life Policy Amount life Policy date issued life Policy Premium Long Term Care long term long term Policy # long term Policy Amount long term Policy date issued long term Policy Premium Auto Auto term Auto Policy # Auto Policy Amount Auto Policy date issued Auto Policy Premium Homeowners or Renters Homeowners or Renters Homeowners or Renters Policy # Homeowners or Renters Policy Amount Homeowners or Renters Policy date issued Homeowners or Renters Policy Premium Personal Umbrella Personal Umbrella Personal Umbrella Policy # Personal Umbrella Policy Amount Personal Umbrella Policy date issued Personal Umbrella Policy Premium Business Owner Business Owner Business Owner Policy # Business Owner Policy Amount Business Owner Policy date issued Business OwnerPolicy Premium Business Liability Business Liability Business Liability Policy # Business Liability Policy Amount Business Liability Policy date issued Business Liability Policy Premium Other (Specify) Other Other Policy # Other Policy Amount Other Policy date issued Other Policy Premium FINANCIAL ADVISOR 1 Name Address Telephone Email Address Accountant Name Address Telephone Email Address Manager/Executive Assistant Name Address Telephone Email Address Attorney Name Address Telephone Email Address Health Insurance Agent Name Address Telephone Email Address P and C Insurance Agent Name Address Telephone Email Address Investment Banker Name Address Telephone Email Address Life Insurance Agent Name Address Telephone Email Address Lender/Mortgage Broker Name Address Telephone Email Address Additional Information Signature Date
