Client Information Worksheet | Farm Bureau Financial Services

Personal

*Advisor Name

*First Name

Prefix

M.I.

*Last Name

*Social Security Number (XXX-XX-XXXX)

*Date Of Birth (MM/DD/YYYY)

*US Citizen/Permanent Resident?

Yes

*Marital Status

Number of Dependents (Including Self)?

Contact/Address

*Home Phone

Business Phone

Extension

Cell Phone

E-mail Address

Address of Residence – No P.O. Box

*Street

Apt/Suite Number

*City

*State

*Zip

Country

Mailing Address - P.O. Box allowed (Only use if different from Address of Residence)

Street

Apt/Suite Number

City

State

Zip

Country

Employment

*Employment Status (If retired or unemployed, provide previous occupation.)

Employer Name

Occupation

Street

Apt/Suite Number

City

State

Zip

Country

Financial

*Annual Income (exclude spouse's income)

*Net Worth (exclude value of home)

*Liabilities (all sources, including mortgage)

*Tax Bracket

*Large Trader - Are you a Large Trader?

Yes

A “large trader” is defined as a person who, directly or indirectly, through the exercise of “investment discretion,” effects transactions in NMS securities (largely exchange-listed securities and options) equal to or exceeding in the aggregate two million shares or $20 million on any calendar day, or 20 million shares or $200 million over the course of a calendar month.

Associations

* Broker Dealer Associations – Is the client or an immediate family member affiliated with or employed by another Broker/Dealer member firm? If yes, indicate the firm and position. (Proper authorization must be obtained from the member firm).

Yes

* Controlling Security Positions – Is the client or an immediate family member any of the following: director, shareholder with 10% or more of the stock, or a policy-making executive officer of a publicly traded company? If yes, indicate company, position, and symbol.

Yes

* Employee Relationship – Is the client related to an employee of FBL Financial Group, Inc.? If yes, please indicate employee name, employee SSN, relationship to employee and the class.

Yes

Employee's Full Name

Employee SSN (if known)

Class

Employee-immediate relationship

Employee-extended relationship

Relation to Employee

Securities & Services offered through FBL Marketing Services, LLC, 5400 University Avenue, West DesMoines, IA 50266,877-860-2904, Member SIPC. Advisory services offered through FBL Wealth Management, LLC.

All the fields marked as * are required before submitting the worksheet.

Personal

Contact/Address

Employment

Financial

Investment Background

Associations