Client Profile Information Nationwide Securities, LLC Nationwide Financial General Agency, Inc.

Transcription

1 Client Profile Information Nationwide Securities, LLC Nationwide Financial General Agency, Inc. Use this form to collect Client Profile information on behalf of securities products offered by Nationwide Securities, LLC (NSLLC) and/or fixed annuity products offered by Nationwide Financial General Agency, Inc. (NFGA). For securities products offered by NSLLC, such information will be used to meet various regulatory requirements, including but not limited to, suitability determinations. Accounts that are established will be maintained by the product issuer and NSLLC will be the broker-dealer of record. For fixed annuity products, such information is being requested by NFGA. Such information will be used to meet various regulatory requirements, including but not limited to suitability determinations. Accounts that are established will be maintained by the product issuer. A Client Profile Information form must either be on file or attached when opening a new account. Print out and fill in using CAPITAL letters and black ink. All changes should be crossed out in a legible manner, corrected, and initialed and dated by the client. Client Details Complete all fields for the appropriate client type. A legal address and one primary phone number is required for all clients. Person Prefix Client Name Suffix Also Known As Date of Birth (mm/dd/yyyy) SSN Gender Marital Status Entity - Business Entity Name TIN Doing Business As Type of Business Website Address (if applicable) Entity - Trust Trust Type: Charitable Family Irrevocable Irrevocable Living Living Revocable Testamentary Trust Name SSN / TIN Trust Established Date (mm/dd/yyyy) Last Amendment Date (mm/dd/yyyy) Governing State of law (State Trust Established) Number of Trustees Number of Trustees Required to Authorize Investment Decisions Trustee Approval: Can Act Independently Cannot Act Independently Contact Information Legal Address (no PO boxes permitted) The following investments are permitted under the trust agreement: Variable Life Insurance Stocks Fixed Life Insurance Bonds Variable Annuities Options Fixed Annuities Margin Accounts Mutual Funds Other: Mailing Address (if different from legal) Address Line 1 Address Line 1 Address Line 2 Address Line 2 City, State Zip Code City, State Zip Code Country Country NFM-12427AO.1 ( ) Page 1 of 6

2 Does the client reside in a nursing home or assisted living facility? Yes No Phone Numbers Client Profile Information, Home Primary Secondary Cell Primary Secondary Work Primary Secondary Fax Primary Secondary Primary Address Secondary Address I authorize NSLLC and/or NFGA to send information to me electronically, including but not limited to, my annual privacy statement and legal mailings. Employment Information For all individual clients, select an employment status and provide information. Employment Status Employed Self-Employed Retired Unemployed Student Homemaker Disabled Other Name of Employer Address Line 1 Occupation Address Line 2 Job Title Financial Information Person City, State Zip Code + = Approximate Annual Salary Other Household Annual Income Total Household Annual Income Approximate Monthly Recurring Expenses Total Number of Wage Earners Number of Dependents Tax Bracket: 0% 10% 15% 25% 28% 33% 35% or higher Do you have a Formal Financial Plan? (If yes, attach the plan) Yes No Any anticipated non-recurring expenses? No Yes, provide details below Amount: Time frame years Describe expenses: Financial Information Entity Gross Annual Revenue or Income Net Annual Revenue or Income - = Total Entity Assets Total Entity Liabilities Total Entity Net Worth Power of Attorney Do you have a Power of Attorney? Yes, Name: No Name: NFM-12427AO.1 ( ) Page 2 of 6

3 Net Worth Information Complete all information. Limit one account per row. Not required for entity accounts. Exclude primary residence. Client Profile Information, Type of Asset 1 Type of Product 2 Product Sponsor Product Name & Share Class Owner 3 Value Options for use above: 1 Type of Asset: Short-Term (ST) Education (ED) Retirement (RET) Non-Retirement (NR) Other 2 Type of Product: Checking (CHK) Savings (SAV) Money Market Fund (MM) Brokerage (BKG) Mutual Funds (MF) Variable Annuity (VA) Fixed Annuity (FA) Life Insurance (LIFE) Other Overall Client Risk Tolerance 3 Owner: Client (C) Spouse (S) Jointly (J) Total Assets (Sum of all accounts.) Estimated Liabilities (Excluding Mortgage) Total Net Worth (Sum of Assets Minus Liabilities) Select the risk tolerance that reflects your overall tolerance. Low High Conservative Moderately Conservative Moderate Moderately Aggressive Aggressive I want to preserve my initial principal in my investments, with minimal risk, even if that means this account does not generate significant income or returns and may not keep pace with inflation. I am willing to accept low risk to my initial principal, including low volatility, to seek a modest level of portfolio returns. I am willing to accept some risk to my initial principal and tolerate some volatility to seek higher returns and understand I could lose a portion of the money invested. I am willing to accept high risk to my initial principal, including high volatility, to seek high returns over time and understand I could lose a portion of the money invested. I am willing to accept maximum risk to my initial principal to aggressively see maximum returns and I understand I could lose most, or all, of the money invested. NFM-12427AO.1 ( ) Page 3 of 6

4 Client Profile Information, Investment Experience Enter the approximate number of years of experience to date for each investment type listed. Investment Years Experience Investment Years Experience Individual Bonds Certificate of Deposits Fixed Annuities Margin Accounts Municipal Securities Mutual Funds Broker-Dealer or Public Company Affiliations Individual Stocks/ETFs Option Contracts Variable Annuities Variable Life Policies Other: For all clients, answer all questions. If you answer yes to any of the questions, provide the requested information. Are you an employee of this Broker-Dealer? Yes No Are you an employee of another Broker-Dealer? Yes No Name of Broker-Dealer: Are you related to an employee of this Broker-Dealer? Yes No Name of Employee: Are you related to an employee of another Broker-Dealer? Yes No Name of Employee: Name of Broker-Dealer: Are you or anyone with an interest in this account, a senior officer, director or 10% or more shareholder of a public company? Yes No Company Name: Symbol: Are you or any member of your immediate family affiliated with or employed by a member of a stock exchange or the Financial Industry Regulatory Authority (FINRA)? Yes No Name of Entity: Explain the Affiliation: U.S. Patriot Act Information For all clients, select citizenship type. If resident or non-resident alien is selected, a country of citizenship is required. What is your citizenship: U.S. Citizen Resident Alien Non-Resident Alien Citizenship Country: Is this a private bank account? Yes No Is this account for a Foreign Financial Institution? Yes No If yes, is the Bank a Central Bank? Yes No Are you or anyone with an interest in this account either, (1) a senior military, governmental or political official in a non-u.s. country, or (2) closely associated with an immediate family member of such an official? First & Last Name: Country: Office Held: NFM-12427AO.1 ( ) Page 4 of 6

5 Client Profile Information, Identification Information All individuals must provide at least one unexpired identifying document. Resident and non-resident aliens must provide two unexpired identifying documents. Document 1 Document 2 Identification Number State or Country of Issue Identification Number State or Country of Issue Issue Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy) Issue Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy) Authorized Signer/Trustee Identification Information All entity clients must provide the information requested for all authorized person(s). Authorized Person 1 Name Address Line 1 Address Line 2 Title: Executor Administrator Trustee Authorized Person Other: Identification Type: City, State Zip Identification Number State or Country of Issue Country Issue Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy) Authorized Person 2 Name Address Line 1 Address Line 2 Title: Executor Administrator Trustee Authorized Person Other: Identification Type: City, State Zip Identification Number State or Country of Issue Country Issue Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy) Authorized Person 3 Name Address Line 1 Address Line 2 Title: Executor Administrator Trustee Authorized Person Other: Identification Type: City, State Zip Identification Number State or Country of Issue Country Issue Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy) NFM-12427AO.1 ( ) Page 5 of 6

6 Client Profile Information, Certification TAXPAYER CERTIFICATION: Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number; and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in IRS instructions); and (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Note: This is a US Account; therefore no FATCA code applies. CERTIFICATION INSTRUCTIONS: You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. The signature provided below is that of the primary account holder. Owner Name (Print) Signature of U.S. Person Date (mm/dd/yyyy) Client Signature(s) By signing below, I hereby acknowledge the following: I have received and read this Client Profile Information Form. I certify that all the information I have provided is complete and accurate to the best of my knowledge, including my financial background and investment objectives. Furthermore, I will notify NSLLC and/or NFGA in writing if there are any changes to my investment objectives, risk profile, or financial profile. Owner or Authorized Signer/Trustee Name (Print) Owner or Authorized Signer/Trustee Signature Date (mm/dd/yyyy) Authorized Signer/Trustee Name (Print) Authorized Signer/Trustee Signature Date (mm/dd/yyyy) Authorized Signer/Trustee Name (Print) Authorized Signer/Trustee Signature Date (mm/dd/yyyy) Agent or Registered Representative Signature(s) By signing below, I hereby acknowledge the following: To the best of my knowledge, the information provided is accurate and complete. That I/we have personally examined the document(s) listed in Identification Type section of this form and reasonably believe the information confirms the identity of the customer(s). Agent/RR Name (Print) Agent/RR Signature RR #/Split Code Branch Code Date Agent/RR Name (Print) Agent/RR Signature RR #/Split Code Branch Code Date Agent/RR Name (Print) Agent/RR Signature RR #/Split Code Branch Code Date! BEFORE YOU MAIL, HAVE YOU: Signed the Client Profile Information Form and Account Questionnaire & Agreement? Completed and Enclosed: Product Sponsor Paperwork and any additional documentation that is required? Enclosed your check made payable to the Product Sponsor (if applicable)? NFM-12427AO.1 ( ) Page 6 of 6