Valicenti Advisory Services, Inc.

Section I: Services Requested

Investment Advisory Services
Business Services
Financial Planning
Bill Paying
Tax Services

How were you referred to VASI?

Your reason for switching to VASI:

Previous advisor:

Section II: Contact Information (client and spouse)

CLIENT:

Legal Name:

Legal Address: (no P.O. Boxes)

Mailing Address: (if different from legal address)

SS#:

DOB:

Driver’s License #:

State:

Phone:

Cell:

Email:

Employer:

Occupation:

Business Address:

Business Phone:

Business Email:

Preferred method of contact:

Home Email

Work Email

Home Phone

Work Phone

Cell Phone

SPOUSE:

Legal Name:

Legal Address: (no P.O. Boxes)

Mailing Address: (if different from legal address)

SS#:

DOB:

Driver’s License #:

State:

Phone:

Cell:

Email:

Employer:

Occupation:

Business Address:

Business Phone:

Business Email:

Section III: Beneficiary Information

Client Primary Beneficiary:

Relationship:

Beneficiary Weighting:

SS#:

DOB:

Phone:

Mailing Address:

Client Contingent Beneficiary:

Relationship:

Beneficiary Weighting:

SS#:

DOB:

Phone:

Mailing Address:

Spouse Primary Beneficiary:

Relationship:

Beneficiary Weighting:

SS#:

DOB:

Phone:

Mailing Address:

Spouse Contingent Beneficiary:

Relationship:

Beneficiary Weighting:

SS#:

DOB:

Phone:

Mailing Address:

Section IV: Account Information

Account Type

Additional Account Information
529 College Savings, Custodial Account

Child’s Legal Name:

Relationship:

SS#:

DOB:

Phone:

Mailing Address:

Account Features (not applicable for all accounts)

SchwabOne Checks:

Yes

No

SchwabOne Visa Card:

Yes

No

eDelivery Enrollment:

Yes

No

eDelivery Email Preference:

Electronic Tax Payments:

Yes

No

MoneyLink (include “voided” check):

Yes

No

Cash Remittance Amount: $

Remittance Date and Frequency:

Tax Withholding on Remittance: Federal %

State %

Section V: Estate Planning and Services

Attorney:

Last Will and Testament included

Letters of Testamentary included (original or certified copy dated within 60 days)

Death Certificate included (original or certified copy)

Estate Tax I.D. Number:

Decedent’s Name:

SS#:

DOB:

DOD:

Section VI: Insurance Services

Coverage listed below is available through our affiliate, Valicenti Insurance Services, Inc.

Automobile
Homeowners
Life
Long-Term Care
Watercraft
Renters
Disability
Business
Recreational Vehicle(s)
Umbrella
Healthcare

Would you like an introduction?:

Yes

No

Section VII:

Tax Services

Personal Income Tax Return
Business Entity Return: 1120; 1120S or 1065
Estate and Trust Return
Tax Planning
Complimentary review of prior year individual 1040 return

Business Services

Business Consulting
Bookkeeping
QuickBooks Account Set-up
Payroll
Sales Tax

If requesting services above:

Previous 1-2 years of tax returns with tax documents included

Section VIII: Client Bill Paying Services

Establish a client checking account
Bills paid on the 10th and 20th of each month
Automatic transfers between your brokerage account and your checking account
Monthly reconciliation of bank statements
Quarterly reports mailed to you

Would you be interested in this service?:

Yes

No

Section IX: Other Financial Information

Property 1 Address:

Property 1 Value: $

Mortgage Balance: $

Terms (length/interest rate):

Vehicle Make:

Model:

Year:

Estimated Value: $

Additional Household Driver:

DOB:

Driver’s License #:

State:

Current Income: Annual: $

Monthly: $

Current Expenditures: Annual: $

Monthly: $

Current Retirement Savings Rate: Annual: $

Monthly: $

Current Savings Rate (Excluding Retirement Savings): $

Expected Income Needed in Retirement: $

Anticipated Retirement Age(s):

You:

Spouse:

Expected Sources of Retirement Income:

Retirement Savings (Excluding Pensions and Social Security Benefits): $

Section X: Other Financial Information (continued)

Expected Pension Benefit(s) at Retirement Age: You: $

Spouse: $

Expected Social Security Benefit(s) at Retirement Age: You: $

Spouse: $

Life Insurance Death Benefit and Cash Values: $

Annuities: $

Rental Property: $

Other Sources: $

Checking Account Values: $

Savings Account Values: $

Other Liabilities & Terms:

Any Significant Future Spending Plans?:

Yes

No

Any Significant Wealth Increase Anticipated?:

Yes

No

Gifting Plans?:

Yes

No

Special Needs Planning?:

Yes

No

Section XI: Investment Approach & Tolerance

Any income need:

Income need as a percent of investments:

Desired meeting frequency:

Annually

Semi-Annually

Other

Which of the following best describes your investment objective(s)?

Preservation of capital and focus on current income
A balance between capital appreciation and current income
Capital appreciation with little or no need for current income

Further explanation/Description:

Investment restrictions/Other important information* (if none, indicate “None”):

To prepare for the first meeting, we ask that you upload statements for brokerage and retirement accounts. Please click the below “choose files” to upload.
Choose files Files

NOTES:

IMPORTANT DISCLOSURE INFORMATION

Intended Purpose: This Organizer has been created by Valicenti with the assumption that the client will choose to implement planning recommendations and investment management services in conjunction with Valicenti and its affiliates. Although the client is under no obligation to further engage Valicenti, or its affiliates, for implementation services, in the event that the client chooses not to do so, Valicenti takes no responsibility for any implementation errors, lapses, or deficiencies. Reliance on Information Provided: Valicenti shall rely upon information provided by you, and will not verify the accuracy of any such information that you have provided. Accordingly, in the event that any such information provided is inaccurate or incomplete, the corresponding recommendations and/or conclusions could be inaccurate or incomplete. It remains your responsibility to notify Valicenti of any changes in the information provided. Please Remember: Different types of investments involve varying degrees of risk. Therefore, it should not be assumed that future performance of any specific investment or investment strategy (including the investments and/or investment strategies recommended and/or undertaken by Valicenti), or any non-investment related content or recommendations, will be profitable or prove correct. Unless indicated to the contrary in the spaces directly above, there will be no restrictions on our investment advisory services other than to manage the account(s) in accordance with your investment objective. Please remember that it remains your responsibility to advise Valicenti, in writing, if there are any changes in the information provided above, including any change in your personal/financial situation, for the purpose of reviewing/revising previous recommendations and/or results, or if you would like to impose, add, or to modify any reasonable restrictions to Valicenti's investment advisory services.

*Please Note: PPQ-Reliance on Information Provided: Valicenti shall rely upon information provided by you on the PPQ, and will not verify the accuracy of any such information that you have provided. Accordingly, in the event that any such information provided is inaccurate or incomplete, the corresponding recommendations and/or conclusions could be inaccurate or incomplete. It remains your responsibility to notify Valicenti of any changes in the information provided.

Personal Planning Questionnaire

Section I: Services Requested

Section II: Contact Information (client and spouse)

Section III: Beneficiary Information

Section IV: Account Information

Section V: Estate Planning and Services

Section VI: Insurance Services

Section VII:

Tax Services

Business Services

Section VIII: Client Bill Paying Services

Section IX: Other Financial Information

Section X: Other Financial Information (continued)

Section XI: Investment Approach & Tolerance

Valicenti Advisory Services, Inc.

Contact Info