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.1 Family Information2 Income3 Business Assets & Real Estate4 Investments/Cash Assets5 Liabilities6 Life Insurance7 Net WorthDate* Date Format: MM slash DD slash YYYY Individual 1:* First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital Status:SinglePartnerMarriedDivorcedWidowedIndividual 2: First Middle Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Children:First Child Name First Last SexFemaleMaleDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeSecond Child Name First Last SexFemaleMaleDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeThird Child Name First Last SexFemaleMaleDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeForth Child Name First Last SexFemaleMaleDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country CellPhoneEmail 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.Household Income & EmploymentIndividual 1:Individual 1 Gross Yearly SalaryIndividual 1 Bonus/CommissionsIndividual 1 Total IncomeAverage Tax RefundOccupationBusiness/Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mark if this Individual is self-employed Self-employedIndividual 2:Individual 2 Gross Yearly SalaryIndividual 2 Bonus/CommissionsIndividual 2 Total IncomeAverage Tax RefundOccupationBusiness/Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mark if this individual is self-employed. Self-employedOther IncomeRentalsRoyaltiesFeesCommissionTrust Income2nd BusinessEmployment and Other Income Quick LookIncome TotalNeither 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.Business Assets & Real EstatePlease list the current Business Assets & Real Estate (Primary Residence, Investment Properties, Business Assets)Description of the 1st Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly Expenses.Net Cash FlowAfter expensesLoan 1 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)2nd Business Asset or Real EstateDescription of the 2nd Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpensesNet Cash FlowAfter ExpensesLoan 2 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)3rd Business Asset or Real EstateDescription of the 3rd Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpensesNet Cash FlowAfter ExpensesLoan 3 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)4th Business Asset or Real EstateDescription of the 4th Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpensesNet Cash FlowAfter ExpensesLoan 4 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)5th Business Asset or Real EstateDescription of the 5th Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpencesNet Cash FlowAfter ExpensesLoan 5 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)6th Business Asset or Real EstateDescription of the 6th Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpensesNet Cash FlowAfter ExpensesLoan 6 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)7th Business Asset or Real EstateDescription of the 7th Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpensesNet Cash FlowAfter ExpensesLoan 7 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)8th Business Asset or Real EstateDescription of the 8th Business Asset or Real Estate:ValueThis is:my Primary Residencemy Other Residencea Rentala BusinessRentPaymentAverage Monthly ExpensesNet Cash FlowAfter ExpensesLoan 8 BalanceLoan TermHow many years is the loan amortized for?15 Year20 Year30 YearLoan TypeFixedInterestARMAPR(Annual Percentage Rate)I have more entries to make. Yes NoNotes:Additional Business Asset or Real Estate EntriesTotal additional Income from Business Asset or Real EstateSum all of the additional income from the Business Assets or Real Estate entries listed in the above "Notes" section.Total additional Loans from Business or Real Estate EntriesSum all of the additional loans from Business or Real Estate 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.Investments/Cash AssetsPlease 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.BalanceContribution2nd Cash Asset or InvestmentDescription of your 2nd Cash Asset or Investment:BalanceContribution3rd Cash Asset or InvestmentDescription of your 3rd Cash Asset or Investment:BalanceContribution4th Cash Asset or InvestmentDescription of your 4th Cash Asset or Investment:BalanceContribution5th Cash Asset or InvestmentDescription of your 5th Cash Asset or Investment:BalanceContribution6th Cash Asset or InvestmentDescription of your 6th Cash Asset or Investment:BalanceContribution7th Cash Asset or InvestmentDescription of your 7th Cash Asset or Investment:BalanceContribution8th Cash Asset or InvestmentDescription of your 8th Cash Asset or Investment:BalanceContributionI have more entries to make. Yes NoNotes:Additional Cash Asset or Investment EntriesTotal additional Cash Asset or Investment EntriesSum 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.LiabilitiesPlease list the current Liabilities (Debt, Credit Cards, Lines of Credit, etc. NOTE: No Mortgages)Description of the 1st Liability:CreditorBalanceAPRMinimum PaymentActual Payment2nd LiabilityDescription of the 2nd Liability:CreditorBalanceAPRMinimum PaymentActual Payment3rd LiabilityDescriptionCreditorBalanceAPRMinimum PaymentActual Payment4th LiabilityDescription of the 4th Liability:CreditorBalanceAPRMinimum PaymentActual Payment5th LiabilityDescription of the 5th Liability:CreditorBalanceAPRMinimum PaymentActual Payment6th Liability:Description of the 6th Liability:CreditorBalanceAPRMinimum PaymentActual Payment7th Liability:Description of the 7th Liability:CreditorBalanceAPRMinimum PaymentActual Payment8th LiabilityDescription of the 8th Liability:CreditorBalanceAPRMinimum PaymentActual PaymentI have more entries to make. Yes NoNotes:Additional Liability EntriesTotal additional LiabilitiesSum 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.Life InsurancePlease list the life insurance you currently own.Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 1 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 2Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 2 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 3Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 3 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 4Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 4 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 5Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 5 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 6Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 6 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 7Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 7 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValuePolicy 8Insurance CompanyInsuredOwnerBeneficiaryPolicy numberAnnual PremiumDeath BenefitStart DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy 8 TypeTermWholeULVULTerm Number of Years LeftWhole Life Cash ValueUL Cash ValueVUL Cash ValueI have more entries to make. Yes NoNotes:Additional Life Insurance EntriesTotal additional Death BenefitSum all of the additional Death Benefit from all additional policies listed in the above "Notes" section.Total additional Cash ValueSum all of the additional Cash value from all additional policies listed in the above "Notes" section.Total additional PremiumsSum all of the additional premiums from all additional policies 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.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 TotalBusiness and Real Estate Value TotalsTotal Investments/Cash Assets Balance:Total Life Insurance Cash ValueLiabilities:Business and Real Estate Loan TotalsLiabilities Total:Non-MortgagesEstimated Net WorthTOTAL ASSETSTOTAL LIABILITIESNET WORTHBusiness and Real Estate:Business and Real Estate (Value - Loans)Life Insurance Death BenefitsTotal Annual Life Insurance PremiumsTotal Death BenefitNeither 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.NameThis field is for validation purposes and should be left unchanged.
