Client Information Worksheet

Client Data & Information Worksheet

Submit completed worksheet via:

Fax: (210) 223-8707 or
Email:

Please assist us in the process of opening your account by providingas much information as possible. Thank you.

Account Owner

Full Name (as you wish to have it listed on account):

Name you prefer to be addressed by:

Social Security Number: Date of Birth:

Home Mailing Address:

City: State: Zip:

Home Phone Number:Mobile Phone Number:

Driver’s License No: Exp. Date: State of Issuance:

Preferred E-mail address:

Are you a U.S. Citizen?Yes No

Marital Status (circle one): Single Married Partner Divorced Widowed

Mother’s Maiden Name (this is security measure in order to establish Online Account Access):

Your Spouse (if applicable)

Spouse’s Full Name:

Name your Spouse prefers to be addressed by:

Spouse’s Social Security Number:Spouse’s Date of Birth:

Employer: Occupation:

Work Phone Number: Mobile Phone Number:

Is your spouse a U.S. Citizen? Yes No, if“No” is Spouse:Resident Alien Non-Resident Alien

Married/Anniversary Date: ______

Your Personal Preferences (so that we may better serve you)

Do you like coffee? Yes No If “Yes”, how do you like it? ______

Preferred Beverage (rank 1 to 3): Bottled Water Diet Coke Coke

Do you like to play golf? Yes No

Do you like to drink wine? Yes No If “Yes”, which do you prefer______

Do you like to attend Spurs games? Yes No

Employer Sponsored Plan Access (circle appropriate one):

AT&T USAA Valero Tesoro Other

IMPORTANT: Please provide this information – this is how we track the status of your Lump Sum Check!

SSN or Customer ID: PIN:

Your Banking Information

Banking Institution Name:

Account Name (exactlyas it appears on your check):

Account Type: Checking / Savings (please circle one)

Routing Number: Account Number:

Important: Please provide one (1) copy of a voided check with this worksheet.

Taking Distribution(s) from your Investment Portfolio

NOTE: Only fill out this section if you plan to start taking distributions from your account IMMEDIATELY.

If you’ve discussed with Dion about taking distributions from your investment portfolio, specifically using the “Rule 72(t)”, please advice us of when you would like the following to occur:

Monthly Income Distribution – 72(t) (if applicable)

In what month would you like to have your monthly distributions started? Please allow 30 days from date of account opening before first distribution of funds:
On what date would you like funds posted to your account? (i.e. 5th of each month)
Do you wish for funds to be deposited to the bank account you listed on this worksheet?
Yes / No
If “No”, please provide your desired banking information to process distributions to:

Banking Institution Name:

Account Name (exactly as it appears on your check):

Account Type: Checking / Savings (please circle one)

Routing Number: Account Number:

Beneficiary Designation- In the event of your death, you will need to identify who you wish to have as your beneficiary (ies). You can identify a Primary as well as a Contingent Beneficiary. If you have your Will established as a Trustor as an Estate, please provide us with the name and contact information of the entity holding the Trust, or the name of the Estate and contact information of the Executor of the Estateon a separate sheet of paper.

Primary Beneficiary Designation(s)

1)Full Name:

Relationship: Gender:Date of Birth: