Data Collection Sheet – Open Source Investments

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2160 8Th St Ste B Mandeville La 70471

Phone: 985-231-0808 Fax: 985-520-0313

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Client Access
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Tax Information

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Personal Information

Name *

First

Middle

Last

Birth Date

SSN *

Address - (Not Po Box) *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address

Same As Home Address
Different Mailing Address

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Email *

Employment Information

Employment Status *

Employed
Retired
Not Employed

Employer

Job Title

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone

Beneficiary Information (For IRA accounts)

Would you like to name Beneficiaries

Yes
No

Beneficiary #1

Name

First

Middle

Last

Birth Date

Relationship

Beneficiary Type

Primary
Contingent

Share %

Beneficiary #2

Name

First

Middle

Last

Birth Date

Relationship

Beneficiary Type

Primary
Contingent

Share %

Beneficiary #3

Name

First

Middle

Last

Birth Date

Relationship

Beneficiary Type

Primary
Contingent

Share %

Beneficiary #4

Name

First

Middle

Last

Birth Date

Relationship

Beneficiary Type

Primary
Contingent

Share %

Financial Information

Household

Total Investable Assets

Cash Reserves

Home Value

Total Mortgage

Credit Card Debt

Car Loans

Other Debt

Financial Information

Individual Information

Annual Income

Social Security

Not taking yet
Already Started

Social Security - Monthly

Social Security - Monthly PIA (the amount you will receive at full retirement age)

Will you have a Pension

No
Yes
Yes - Already Started

Pension Benefit at Retirement (Monthly)

Pension Benefit (Monthly)

Please enter any additional information here.

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