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Northern Pacific Asset Management

Client Information

Please complete this form to provide or update your personal, family, business, and advisor information. Keeping this current helps us serve you better.

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Step 1 of 10
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Section 1 of 10

You & Co-Client

Basic contact information for you and your co-client (if applicable).

Status
Marital Status *
Section 2 of 10

Identity & Compliance

Government-issued identification, tax information, and regulatory compliance.

555-55-5555
555-55-5555
US Citizen? *
Co-Client US Citizen? *
Country of Tax Residence *
Co-Client Country of Tax Residence *
Tax Filing Status *
If filing taxes separately.
Are you or any of your relatives (including parents, in-laws and/or dependents, etc.), living in your home (at the same address), a member of the board of directors, a 10% shareholder, or a policy-making officer or can direct corporate management of policies of a publicly traded company (an "Affiliate")?
Relationship *
Government Jurisdiction *
Section 3 of 10

Health & Employment

Health status, employment details, and trusted contact designation.

Employment *
Co-Client Employment *
A trusted contact- predetermined and designated by you- can be a friend, relative, or anyone you trust. With the aging of the US population, financial exploitation of seniors is a serious and growing problem. Your trusted contact person will be an additional resource for NPAM and Osaic in administering your account, protecting your assets, and addressing possible financial exploitation. NPAM and Osaic will use its discretion in relying on any information provided by the trusted contact person. For more information or questions on providing a trusted contact, contact Northern Pacific Asset Management about how Osaic uses your trusted contact information.
Section 4 of 10

Family

Children, grandchildren, and family obligations.

1

Child 1

555-55-5555
Marital Status ¹ *
US Citizen? ¹ *
2

Child 2

555-55-5555
Marital Status ² *
US Citizen? ² *
3

Child 3

555-55-5555
Marital Status ³ *
US Citizen? ³ *
4

Child 4

555-55-5555
Marital Status ⁴ *
US Citizen? ⁴ *
5

Child 5

555-55-5555
Marital Status ⁵ *
US Citizen? ⁵ *
6

Child 6

555-55-5555
Marital Status ⁶ *
US Citizen? ⁶ *
1

Grandchild 1

Marital Status ¹ *
US Citizen? ¹ *
2

Grandchild 2

Marital Status ² *
US Citizen? ² *
3

Grandchild 3

Marital Status ³ *
US Citizen? ³ *
4

Grandchild 4

Marital Status ⁴ *
US Citizen? ⁴ *
5

Grandchild 5

Marital Status ⁵ *
US Citizen? ⁵ *
6

Grandchild 6

Marital Status ⁶ *
US Citizen? ⁶ *
7

Grandchild 7

Marital Status ⁷ *
US Citizen? ⁷ *
8

Grandchild 8

Marital Status ⁸ *
US Citizen? ⁸ *
9

Grandchild 9

Marital Status ⁹ *
US Citizen? ⁹ *
10

Grandchild 10

Marital Status ¹⁰ *
US Citizen? ¹⁰ *
11

Grandchild 11

Marital Status ¹¹ *
US Citizen? ¹¹ *
12

Grandchild 12

Marital Status ¹² *
US Citizen? ¹² *
Section 5 of 10

Estate & Legal

Estate documents, trusts, and family legal considerations.

Please upload all relevant copies of Last Will and Testament to Secure ShareFile Dropbox.
Please upload all relevant copies of Trust documents to Secure ShareFile Dropbox.
Include name of Trust, type/purpose of Trust, name of Trustee / Co-Trustee, Corporate Trustee, Trust Grantor, Investment Advisor, State/Location of Trust Situs, and any other information you think is relevant. Please upload all relevant copies of Trust documents, financial/asset statements and tax returns to Secure ShareFile Dropbox.
Please review Divorce Preparation Checklist on the next page once you completed the personal section.
Section 6 of 10

Property & Lifestyle

Real estate, insurance considerations, and lifestyle factors.

Section 7 of 10

Financial Priorities

Board memberships, partnerships, and your top financial concerns.

Section 8 of 10

Business

Business ownership and entity details.

Northern Pacific Asset Management, LLC does not provide direct investment banking services. Should you require potential investment banking services, we're able to introduce you to KMS Financial Services, Inc. parent company's affiliate Ladenburg Thalmann & Co, Inc., who specializes in middle-market corporate finance and investment banking services. For more information, please contact Northern Pacific Asset Management or visit https://www.ladenburg.com/investment-banking
Section 9 of 10

Your Advisory Team

Your current professional advisors and service providers.

💼

Financial Advisor

📊

CPA, Enrolled Agent, or Tax Preparer

⚖️

Attorney (Trust & Estate)

🏦

Private Banker

🛡️

Life Insurance Agent

🛡️

Property & Casualty Insurance Agent

⚖️

Business Attorney

💼

Additional Financial Advisor

🏦

Additional Banker

👤

Additional Advisor

👤

Business Manager

🏠

Real Estate Agent

🎭

Talent Agent

👪

Family Counselor

🛡️

Health Insurance Agent

🛡️

Disability Insurance Agent

⚖️

Tax Attorney

Use this space for the contact and relevant information of additional Family/Business Advisors, Agents or Brokers, e.g. Family Counselors, International Real Estate Agents, Property Managers, Attorneys, Accountants, Art Brokers & Appraisers, Bankers, Business or Financial Advisors or Mortgage Brokers.
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Have documents ready for your meeting? Upload tax returns, estate documents, statements, or any files you'd like your advisor to review in advance.
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Section 10 of 10

Consent & Submission

Review the disclosures below, provide your electronic signature, and submit.

Data Protection & Privacy

At Northern Pacific Asset Management, LLC., we deeply value the trust you place in us by sharing your personal and confidential information. This statement is a concise overview of our comprehensive Privacy Policy, tailored to the context of your interaction with this form.

Key Aspects of Our Privacy Approach:

1. Personal Information Handling

In line with our Privacy Policy, we collect personal information such as contact details, financial and commercial information, internet or electronic activity data, and other identifiers. This information is essential for offering and providing our services, operating our business, and ensuring compliance with legal obligations.

2. Purposeful Data Utilization

The information you provide is used to understand and meet your financial needs, facilitate transactions, improve our services, and maintain the security of our networks and systems. We do not sell your personal information for third-party promotional purposes.

3. Data Security Measures

Aligning with our Privacy Policy, we employ robust security measures, including SSL encryption, to protect your data during transmission and storage, mitigating risks of unauthorized access and data breaches.

4. Disclosure and Sharing of Information

Consistent with our Privacy Policy, we may disclose personal information to service providers, business partners, and governmental authorities as necessary for business operations, legal compliance, and service provision.

5. Your Privacy Rights

You have rights regarding your personal information, including the right to access, update, and request deletion. Our practices align with federal and state laws, including the California Consumer Privacy Act (CCPA), ensuring your right to non-discrimination in services.

6. Ongoing Updates and Transparency

Our Privacy Policy may be updated periodically. We commit to keeping you informed of any significant changes and encourage you to review the policy regularly.

For a full understanding of how we manage and protect your personal information, we encourage you to review Osaic Wealth, Inc. detailed Privacy Policy.

If you have any questions or concerns regarding the handling of your data, please do not hesitate to contact our customer service team. Trust and transparency are the pillars of our relationship with you.

Thank you for your trust in Northern Pacific Asset Management, LLC.

Legal Disclosure

This form is provided for informational purposes only and does not constitute investment, legal, or tax advice. The information you provide will be used to facilitate your advisory discussion and does not create or modify any advisory agreement. All investments involve the risk of potential investment losses and no strategy can assure a profit. Please consult with a qualified professional for specific legal, tax, or accounting advice. Northern Pacific Asset Management and Osaic Wealth do not provide tax or legal advice.

Thank You!

Your client information has been submitted successfully. Your advisory team at Northern Pacific Asset Management will update your records accordingly.

A confirmation will be sent to the email you provided. If you need to make changes, please contact your advisor directly at (832) 559-3771.