Form

LEGACY Financial Life Professional Contact Information
LEGACY FLP Name*
LEGACY FLP Email Address*
LEGACY FLP Mobile Phone*
Contact Information
This is the information that our service providers will use to contact the client
Please make sure to fill-out all required fields. Put N/A if not applicable.
Client First Name*
Client Last Name*
Address*
Address 2
City*
Postal Code*
Phone*
Email*
Date of Birth*
Client Real Estate Details
Do you own a personal residence?*
If Yes what is your mortgage amount: $*
Line of credit amount (HELOC): $*
Line of credit (HELOC) monthly payment: $*
Property tax amount: $*
Assessed value of residence: $*
Monthly mortgage amount: $*
Do you own a rental property portfolio?*
Market value of current portfolio: $*
Total monthly mortgage payments on rental portfolio: $*
Gross monthly rental income: $*
Total property tax on rental portfolio: $*
Total outstanding debt obligations (1st mortgage, 2nd mortgage,*
Client Personal Wealth Details
Total household income: $*
Total RSP investments: $*
Non RSP investments (TFSAs, stocks, mutual funds, other): $*
Credit card balance: $*
Credit card monthly payments: $*
Loans balance: $*
Loans monthly payments: $*
Line of credit balance: $*
Line of credit monthly payments: $*
Select the product/service(s) your client wants more information about from a licenced agent/provider such as an EMD (Exempt Market Dealer):
REIT (Real Estate Investment Trust)

REIT (Real Estate Investment Trust)
MIC (Mortgage Investment Corporation)

MIC (Mortgage Investment Corporation)
Mortgage Fund

Mortgage Fund
Insurance

Insurance
Banking

Banking
Other Service Request
Limited Partnership

Limited Partnership
Financial Life Professional notes for Service Provider
Confirmation of informed consent
Referral requires completed consent form. Please Put full Name below if everything above is true.
Signature*
Signed Consent Form*

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LEGACY Financial Life Professional Contact Information

Contact Information

Client Real Estate Details

Client Personal Wealth Details

Select the product/service(s) your client wants more information about from a licenced agent/provider such as an EMD (Exempt Market Dealer):

Confirmation of informed consent