Confidential Questionnaire New

Please complete this financial questionnaire to the best of your ability with as much detail as possible. Completing this questionnaire will allow us to properly assess your financial situation and make those recommendations that will assist you in meeting your wealth building strategies.

1Family Information

2Income

3Business Assets & Real Estate

4Investments/Cash Assets

5Liabilities

6Life Insurance

7Net Worth

Date*
MM slash DD slash YYYY
Individual 1:*
First Middle Last
Date of Birth*
Marital Status:
Individual 2:
First Middle Last
Date of Birth
Children:
First Child Name
First Last
Sex
Date of Birth
Hidden
Age
Second Child Name
First Last
Sex
Date of Birth
Hidden
Age
Third Child Name
First Last
Sex
Date of Birth
Hidden
Age
Forth Child Name
First Last
Sex
Date of Birth
Hidden
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell
Phone
Email
Email
Neither Vault AIS nor its representatives give legal, accounting or tax advice or interpretation. Please consult your legal, accounting or tax advisor for such advice. For questions, please visit www.vaultais.com or submit them via e-mail to info@vaultais.com
Copyright © 2013 Vault AIS.

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Household Income & Employment
Individual 1:
Individual 1 Gross Yearly Salary
Individual 1 Bonus/Commissions
Individual 1 Total Income
Average Tax Refund
Occupation
Business/Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mark if this Individual is self-employed
Mark if this Individual is self-employed
- Self-employed
Individual 2:
Individual 2 Gross Yearly Salary
Individual 2 Bonus/Commissions
Individual 2 Total Income
Average Tax Refund
Occupation
Business/Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mark if this individual is self-employed.
Mark if this individual is self-employed.
- Self-employed
Other Income
Rentals
Royalties
Fees
Commission
Trust Income
2nd Business
Employment and Other Income Quick Look
Income Total
Neither Vault AIS nor its representatives give legal, accounting or tax advice or interpretation. Please consult your legal, accounting or tax advisor for such advice. For questions, please visit www.vaultais.com or submit them via e-mail to info@vaultais.com
Copyright © 2013 Vault AIS.

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Investments/Cash Assets
Please list the current Investments and Cash Assets (401k, IRA, Roth IRA, 403b, CDs, Savings, Checking, Bonds, Mutual Funds, etc.)
Description of your 1st Cash Asset or Investment.
Balance
Contribution
2nd Cash Asset or Investment
Description of your 2nd Cash Asset or Investment:
Balance
Contribution
3rd Cash Asset or Investment
Description of your 3rd Cash Asset or Investment:
Balance
Contribution
4th Cash Asset or Investment
Description of your 4th Cash Asset or Investment:
Balance
Contribution
5th Cash Asset or Investment
Description of your 5th Cash Asset or Investment:
Balance
Contribution
6th Cash Asset or Investment
Description of your 6th Cash Asset or Investment:
Balance
Contribution
7th Cash Asset or Investment
Description of your 7th Cash Asset or Investment:
Balance
Contribution
8th Cash Asset or Investment
Description of your 8th Cash Asset or Investment:
Balance
Contribution
I have more entries to make.
- Yes
- No
Notes:
Additional Cash Asset or Investment Entries
Total additional Cash Asset or Investment Entries
Sum all of the additional Cash Asset or Investment entries listed in the above "Notes" section.
Neither Vault AIS nor its representatives give legal, accounting or tax advice or interpretation. Please consult your legal, accounting or tax advisor for such advice. For questions, please visit www.vaultais.com or submit them via e-mail to info@vaultais.com
Copyright © 2013 Vault AIS.

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Liabilities
Please list the current Liabilities (Debt, Credit Cards, Lines of Credit, etc. NOTE: No Mortgages)
Description of the 1st Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
2nd Liability
Description of the 2nd Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
3rd Liability
Description
Creditor
Balance
APR
Minimum Payment
Actual Payment
4th Liability
Description of the 4th Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
5th Liability
Description of the 5th Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
6th Liability:
Description of the 6th Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
7th Liability:
Description of the 7th Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
8th Liability
Description of the 8th Liability:
Creditor
Balance
APR
Minimum Payment
Actual Payment
I have more entries to make.
- Yes
- No
Notes:
Additional Liability Entries
Total additional Liabilities
Sum all of the additional liabilities listed in the above "Notes" section.
Neither Vault AIS nor its representatives give legal, accounting or tax advice or interpretation. Please consult your legal, accounting or tax advisor for such advice. For questions, please visit www.vaultais.com or submit them via e-mail to info@vaultais.com
Copyright © 2013 Vault AIS.

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You are almost finished!
This page is your Financial Overview tallied from all of the information you have entered. Although there is nothing new to enter on this page, you MUST select Submit at the bottom or your data will be DELETED!
Check this box to reveal your Financial Overview.
- I will remember to "Submit" at the bottom of the page.
I understand that I MUST select Submit at the bottom or my Data will be lost.
Assets:
Employment Income Total
"Other" Income Total
Business and Real Estate Value Totals
Total Investments/Cash Assets Balance:
Total Life Insurance Cash Value
Liabilities:
Business and Real Estate Loan Totals
Liabilities Total:
Non-Mortgages
Estimated Net Worth
TOTAL ASSETS
TOTAL LIABILITIES
NET WORTH
Business and Real Estate:
Business and Real Estate (Value - Loans)
Life Insurance Death Benefits
Total Annual Life Insurance Premiums
Total Death Benefit
Neither Vault AIS nor its representatives give legal, accounting or tax advice or interpretation. Please consult your legal, accounting or tax advisor for such advice. For questions, please visit www.vaultais.com or submit them via e-mail to info@vaultais.com
Copyright © 2013 Vault AIS.
Name
This field is for validation purposes and should be left unchanged.

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Children:

Household Income & Employment

Individual 1:

Individual 2:

Other Income

Employment and Other Income Quick Look

Business Assets & Real Estate

2nd Business Asset or Real Estate

3rd Business Asset or Real Estate

4th Business Asset or Real Estate

5th Business Asset or Real Estate

6th Business Asset or Real Estate

7th Business Asset or Real Estate

8th Business Asset or Real Estate

Investments/Cash Assets

2nd Cash Asset or Investment

3rd Cash Asset or Investment

4th Cash Asset or Investment

5th Cash Asset or Investment

6th Cash Asset or Investment

7th Cash Asset or Investment

8th Cash Asset or Investment

Liabilities

2nd Liability

3rd Liability

4th Liability

5th Liability

6th Liability:

7th Liability:

8th Liability

Life Insurance

Policy 2

Policy 3

Policy 4

Policy 5

Policy 6

Policy 7

Policy 8

You are almost finished!

Assets:

Liabilities:

Estimated Net Worth

Business and Real Estate:

Life Insurance Death Benefits