New Client – Self Employed Please complete the following form. Web Site Full Name * Gender * Male Female Date of Birth * US Citizen * Yes No Annual Income * Income Type * Salary Dividends Salary & Dividends Other Marital Status * Married Common Law Single Separated Divorced Widowed Smoking Status * Smoker Non-smoker Do You Have A Will? * Yes No Health Status – Health Concerns * Yes No Specify Health Concerns Spousal Information If applicable Full Name Gender Male Female Date of Birth US Citizen Yes No Employment Status Employee Sole Proprietor Incorporated Business Owner Incorporated Professional Partnership (unincorporated) Annual Income Smoking Status Smoker Non-smoker Health Status – Health Concerns Yes No Specify Health Concerns Name of Child Name of Child Name of Child Name of Child Age Age Age Age Number of Grandchildren Number of Grandchildren Number of Grandchildren Number of Grandchildren Personal Insurance Personal Insurance Term Life Permanent Life Disability Critical Illness Long Term Care Employee Benefits Other Advisors Name Name Name Name Profession Profession Profession Profession Email Email Email Email Phone Phone Phone Phone Is Mosby authorized to consult with these advisors if necessary? Yes No Client Business Information Business Name Nature of Business Date of Incorporation Entity Type Operating Company Holding Company Other Fiscal Year End * Does the corporation qualify for the small business deduction? Yes No Are there any other companies? Yes No Ownership Shareholder Shareholder Shareholder Shareholder No/Class of Shares No/Class of Shares No/Class of Shares No/Class of Shares FMV FMV FMV FMV ACB ACB ACB ACB PUC PUC PUC PUC Are there any family members who are not involved in the business? Yes No Do you have a buy-sell agreement? Yes No How is the agreement funded? Cash Asset Sale Loan Life Insurance Other If no, are there any succession plans in place? Valuation What is the total fair market value of the business? What was the approximate value of the business when it was acquired? Is the value of the business growing? Yes No Have you completed an estate freeze? Yes No If yes, enter by how much. Have you utilized your Capital Gains Exemption? Yes No If yes, enter how much. Employee Benefits Employee Benefits EPSP DPSP Group RRSP Pension Plan RCA Life, Health, Dental Health Care Spending Account Short/Long Term Disability Critical Illness Are there any individuals whose contributions seriously affect company profits? Yes No Corporate Insurance Corporate Insurance Term Life Permanent Life Disability Critical Illness Additional Information Add any additional information here. Contact Us Call Us 403-850-8692 Name/Company Email Address Phone City Question/Message Submit
