Please fill the form below with your information. If you have any questions please email us at info@kellettfinancial.com. 1Client2Spouse3Children4Financial Goals/Advisors ClientName* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone*Work PhoneCell PhoneFaxEmail* Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Drivers Lic. #If you would rather provide this information over the phone please leave this input empty. S.I.N. #If you would rather provide this information over the phone please leave this input empty. B.C. NumberIf you would rather provide this information over the phone please leave this input empty. Organizational DetailsDo you have a will?*Select...YesNoWhen was it last reviewed?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have Power of Attorney?*Select...YesNoDo you gift to charities?*Select...YesNoFamilyFamily members:*List your immediate family below,your parents and siblings. Please fill client field as "Yes" or "No". Click on the plus sign to add additional entries. NameRelationAddressPhoneDate of BirthClient ExpectationsWhat do you expect from a financial planner?*PreferencesDo you work with more than one financial planner?*Select...YesNoDo you prefer your financial affairs to be consolidated or dispersed?*Select...ConsolidatedDispersedHave you discussed any of the following financial planning areas?*Hold Crtl and click to select multiple itemsIncome ProtectionLifestyle ContinuityHealth ProtectionTax Reduction StrategiesIncome DiversificationEducation PlanningCharitable GivingSuccession PlanningFinancial DetailsTypical bank account balanceHolding Statement RequiredSelect...YesNoStatement FrequencySelect...MonthlyQuarterlySemi AnnuallyAnnuallyStatement Type Mail E-mail Website Review FrequencySelect...MonthlyQuarterlySemi AnnuallyAnnuallyEmployerName of Employer* Address of Employer* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Position* Do you have a financial interest in this or any other business?Select...YesNoAre you Married?*Select...YesNo SpouseSpouse's Name First Last Spouse's AddressPlease enter your spouses address if it differs form your own. Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Spouse's Home PhoneSpouse's Work PhoneSpouse's Cell PhoneSpouse's FaxSpouse's Email* Spouse's Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Drivers Lic. #If you would rather provide this information over the phone please leave this input empty. S.I.N. #If you would rather provide this information over the phone please leave this input empty. B.C. NumberIf you would rather provide this information over the phone please leave this input empty. Spouse's Organizational DetailsDoes your spouse have a will?*Select...YesNoWhen was it last reviewed?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does your spouse have Power of Attorney?*Select...YesNoDoes your spouse gift to charities?*Select...YesNoSpouse's FamilyFamily members:*List your immediate family below,your parents and siblings. Please fill client field as "Yes" or "No". Click on the plus sign to add additional entries. NameRelationAddressPhoneDate of BirthClient Spouse's ExpectationsWhat Does your spouse expect from a financial planner?*Spouse's PreferencesDoes your spouse work with more than one financial planner?*Select...YesNoDoes your spouse prefer your financial affairs to be consolidated or dispersed?*Select...ConsolidatedDispersedHas your spouse discussed any of the following financial planning areas?*Hold Crtl and click to select multiple itemsIncome ProtectionLifestyle ContinuityHealth ProtectionTax Reduction StrategiesIncome DiversificationEducation PlanningCharitable GivingSuccession PlanningSpouse's Financial DetailsTypical bank account balanceHolding Statement RequiredSelect...YesNoStatement FrequencySelect...MonthlyQuarterlySemi AnnuallyAnnuallyStatement Type Mail E-mail Website Review FrequencySelect...MonthlyQuarterlySemi AnnuallyAnnuallySpouse's EmployerName of Employer* Address of Employer* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Position* Does your spouse have a financial interest in this or any other business?Select...YesNoDo you have children?*Select...YesNo ChildrenList information about your children below:Click on the plus sign to add additional children's information. Please fill client field as "Yes" or "No".NameAddressPhoneDate of BirthClient Financial ObjectivesMajor financial objectives include*(ie buying house, paying off a mortgage, buying a car, paying for child’s education,saving for retirement etc.)ObjectiveEstimated CostWhen? AdvisorsLawyer(s)Click on the plus sign to add additional entries. Firm NameAddressPhone Accountant(s)Click on the plus sign to add additional entries. NameCompanyAddressDo they do your tax return? Executor(s)Click on the plus sign to add additional entries. NameRelationAddressPhone Physician(s)Click on the plus sign to add additional entries. NameAddressPhone Additional NotesEmailThis field is for validation purposes and should be left unchanged.