Old North State Wealth Data Gathering Form

Please take a few minutes to fill out the Data Gathering Form below

This will give us a better picture of your financial situation and a brief summary of your goals and objectives.

Name

DOB

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Financial Planning Goals & Objectives

What are your primary financial goals & objectives?

What are your primary financial concerns?

Financial Information

Monthly Income

WAGES

Investment Income

Pension

Social Security

Other

Total

Total Fixed Spending

Total Discretionary Spending

Balance Sheet

Checking

Savings

Traditional IRA

401(k)/403(b)

ROTH 401(k)/403(b)

Other Retirement

Business

Real Estate

Liabilities

Credit Cards

Auto Loans

Other Loans

Business Loans

Mortgage Balance

Mortgage Term

Mortgage Interest Rate

Mortgage Loan Date

Current Investment Strategy

Current Investments

Individual Stocks
Individual Bonds
Mutual Funds
Exchange Traded Funds (ETFs)

Check all that apply

Current Asset Allocation Stocks/Bonds

Do you think your current investments are aligned with your Retirement Income Needs?

Yes
No
No Idea!

On a scale of 1 to 10, how confident are you in your current retirement plan?

Selected Value: 0

Would you like to learn more about how our investment process helps align with your retirement goals?

Old North State Wealth Data Gathering Form

Financial Planning Goals & Objectives

Financial Information

Monthly Income

Balance Sheet

Liabilities

Current Investment Strategy

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