CHIP — Client Household Information Platform

1 Personal

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Your Information

First Name

Middle Name

Last Name

Date of Birth

Social Security Number (optional — you can provide in meeting)

Biological Sex

Marital Status

City of Birth

State of Birth

Your Contact Info

Personal Email

Mobile Phone

Work Email

Home Phone

Home Address

Street Address

Apt / Unit

City

State

ZIP Code

Are you a homeowner?

Driver's License / State ID

You may enter the details below, or upload a photo of your license in the Documents section at the end of this form.

License / State ID Number

Issuing State

Issue Date

Expiration Date

Do you have a spouse or partner?

Your Spouse / Partner

First Name

Middle Name

Last Name

Date of Birth

Social Security Number (optional)

Biological Sex

Email

Mobile Phone

City of Birth

State of Birth

Spouse Driver's License / State ID

Enter the details below, or upload a photo in the Documents section at the end of this form.

License / State ID Number

Issuing State

Issue Date

Expiration Date

Any skipped items will be reviewed in your meeting.

2 Family & Estate

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Do you have children or dependents?

Children / Dependents

Would you like to add a Trusted Contact? Someone we can reach in an emergency

Trusted Contact Name

Email

Phone

Street Address

City

State

ZIP Code

Estate Documents

Do you have a current will?

Do you have a trust?

Do you have a Power of Attorney?

Do you have a Healthcare Proxy / Advance Directive?

Do you have beneficiaries other than your spouse or children?Parents, siblings, grandchildren, friends, charities, trusts, etc.

Other Beneficiaries

Any skipped items will be reviewed in your meeting.

3 Employment & Income

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Are you currently employed?

Employer Name

Occupation / Job Title

Employer Street Address

Employer City

Employer State

Employer ZIP

Your Annual Income (approximate is fine)

Are you self-employed?

Is your spouse / partner employed?

Employer Name

Job Title

Employer Street Address

Employer City

Employer State

Employer ZIP

Annual Income (approximate is fine)

Is your spouse self-employed?

Other Household Income (annual, approximate)

Social Security

Pension

Rental Income

Other Income (alimony, royalties, trust income, etc.)

Total Employment Income (if known)

Expected Changes (next 1–3 years)

Any retirement, career changes, inheritance, or other shifts we should know about?

Any skipped items will be reviewed in your meeting.

4 Assets & Accounts

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Bank Accounts (checking, savings, money market, CDs)

Investment Accounts (individual, joint, trust, UTMA)

Retirement Accounts (IRA, Roth, 401(k), 403(b), pension, HSA)

Annuities

Real Estate

Any skipped items will be reviewed in your meeting.

5 Liabilities

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Mortgage(s)

Other Loans (auto, student, personal)

Credit Cards

Any skipped items will be reviewed in your meeting.

6 Insurance

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Life Insurance

Other Coverage

Do you have Disability Insurance?

Carrier / Source (e.g., employer group, individual policy)

Do you have Long-Term Care Insurance?

Carrier

Health Insurance Source

Do you have an Umbrella Policy?

Coverage Amount

Any skipped items will be reviewed in your meeting.

7 Upload Documents

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Recent statements are required as part of your intake. Please upload statements from all of your investment, retirement, and bank accounts. Drag files into any box, or tap to browse — PDFs, photos, Word, and Excel files are all supported.

Driver's License (photo)Choose files

Front and back, for both you and your spouse if applicable. A phone photo is acceptable.

Most Recent Tax Return (1040)Choose file

Drag file here, or tap "Choose file"

Recent Pay Stub(s)Choose file

Drag files here, or tap "Choose file"

Investment Account StatementsChoose files

Most recent statement from each account — drag multiple files at once

Bank Statement(s)Choose files

Optional — drag files here

Social Security StatementChoose file

Available free at ssa.gov/myaccount

Insurance PoliciesChoose files

Life, disability, LTC, or umbrella declarations pages

Estate DocumentsChoose files

Will, trust, Power of Attorney, Healthcare Proxy

Additional DocumentsChoose files

Annuity contracts, 401(k) summary plan descriptions, etc.

Any missing documents may be provided before your first meeting.