Confidential Questionnaire

Date*

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

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Age

Second Child Name

First Last

Sex

Date of Birth

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Age

Third Child Name

First Last

Sex

Date of Birth

This field is hidden when viewing the form

Age

Forth Child Name

First Last

Sex

Date of Birth

This field is hidden when viewing the form

Age

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell

Phone

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 & 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

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.

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.

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.

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.

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

Phone

This field is for validation purposes and should be left unchanged.