Client - Personal Information

Client Information:

Name:

Social Security #:

Date of Birth:

Phone Number

Spouse Information:

Spouse Name:

Spouse Social Security #:

Spouse Date of Birth:

Spouse Phone Number

Additional Contact Information:

Address:

Preferred Email:

May we use this email to contact you in the future?

Yes

Will not be used for solicitation or advertising. Only for work related matters.

Residence School District:

Reside inside a Village/City?

Yes

If Yes, Village/City Name:

Did you move your residence in 2025?

Yes

Date of Move:

Provide Old Address:

Old School District, if different:

During 2025 did you buy or sell any type of virtual currency or NFT - (IE: bitcoin/tokens)

Yes

DRIVER'S LICENSE INFORMATION

Name:

DL #:

ISSUE DATE:

EXP. DATE:

Spouse Name:

Spouse DL #:

SPOUSE ISSUE DATE:

SPOUSE EXP. DATE: