Personal Profile

Please complete this form. You'll need your passport or driver license information to complete the form. All information provided is strictly confidential.

Legal Name*
Prefix First Middle Last Suffix
Prefer to be called:
Preferred Name
Sex*
Please choose what is listed on your passport (or driver license if no passport)
Residential Address*
Street Address Address Line 2 City State ZIP Code
Length of time at current address*
How long have you lived there?
County (NOT country)*
In which COUNTY is your address located?
Is your mailing address the same as your residential address?*
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email*
Home/Cell Phone*
Work Phone
Other Phone
Date of Birth*
Place of Birth (City/Town/Village)*
Country of Birth*
US Citizen?*
- Yes
- No
If no, what nationality?*
Are you a US resident alien?*
- Yes
- No
Are you a citizen of any other countries?*
- Yes
- No
Other citizenships*
Please list the countries of which you are a citizen
Are you a tax resident of any other countries?*
Do you pay taxes in other countries?
- Yes
- No
Other tax residency*
Please list the countries where you pay taxes
Social Security Number or TIN
We will need this for any IRS communications.

show Social Security Number or TIN
Do you currently have a valid USA passport?*
- Yes
- No
Passport Number*

show Passport Number
Expiration Date of Passport*
Month
Day
Year
Driver License Number*

show Driver License Number
Issuing State of Driver License*
Expiration Date of Driver License*
Month
Day
Year
Occupation*
Employment History*
Employment History - for last 3 positions (please include company name and website.)
Where can we see you online?
Please list any professional websites or social media pages which feature your personal profile.
Politically Exposed Person*
Are you or any members of your immediate family a politically exposed person or PEP? Politically Exposed Person (PEP) includes the following: head of state; politician; government official; senior judicial or military official; foreign diplomat; honorary consul; senior executive of state-owned enterprise; an immediate family member of any of the above; and a close associate of any of the above, including any person in a close business relationship or any person in a position to conduct substantial financial transactions on behalf of any of the above.
- Yes
- No
Refused entry to a foreign country*
Have you ever been refused entry to a foreign country?
- Yes
- No
Bankruptcy*
Have you personally, or any entity or legal arrangement of which you have been an officer, director, or a shareholder, ever been adjudicated bankrupt by a Court in any jurisdiction?
- Yes
- No
Entity Crimes*
Have you or any company of which you have been an officer, director, or a shareholder, ever been convicted of any crime (including a financial crime), indicted, or are you or have you been the subject of any investigation or been interviewed in connection with any investigation by bodies such as the SEC, IRS, FBI or any other federal or state law enforcement or regulatory body or any foreign government or agency?
- Yes
- No
Entity Investigation*
Is any legal entity or legal arrangement, of which you are a director, shareholder, manager, trustee, officer or controller currently the subject of a formal enquiry, investigation or disciplinary process by a governmental, professional or regulatory body?
- Yes
- No
Criminal Conduct*
Have you ever been indicted or convicted of any criminal offense or offenses that constitute financial misconduct?
- Yes
- No
Censure/Discipline*
Have you ever been censured or disciplined by any licensing or regulatory authority, had a professional license suspended or revoked, or been subject to a Cease and Desist Order?
- Yes
- No
Litigation*
Are you or have you been declared bankrupt or insolvent or involved in any court proceedings or litigation, whether past, current or impending?
- Yes
- No
Further Information*
If you answered YES to any of the previous eight questions, please provide further details
Source of Wealth*
Please indicate the source(s) of wealth or business that will be transferred into your trust or LLC
- Inheritance
- Business Income
- Employment (e.g. salary, wages, bonus, etc.)
- Gifts
- Loan
- Sale of Shares
- Sale of property
- Other (please provide details below)
Other Source of Wealth*
Please provide details as to the source of wealth
Net worth*
Declare your estimated net worth - nearest USD$M
Asset Holdings*
Describe your significant asset holdings and where they are located
Location of activities*
Describe the geographical location of your business/investment activities
Marital Status*
- Never Married
- Divorced
- Widowed
- Married
Name of Spouse?*
First Middle Last
Date of Marriage
Number of dependents
Family
Do you have children?*
- Yes
- No
Children's Names and Ages*
Add additional children by clicking the "+" icon to the right
First Name Last Name Date of Birth
Do you have an existing Will?
- Yes
- No
Have you ever executed a trust (either revocable or irrevocable)?
- Yes
- No
Have you ever filed a Federal Gift Tax Return?
- Yes
- No
Do you have an existing General Power of Attorney?
- Yes
- No
Thank you for completing this worksheet! Be sure to click the Submit button below and look for the green checkmark for success. If you don't see the green checkmark, please review the worksheet for any missing fields. Missing fields will be highlighted in red.
Email
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LayRoots
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