Confidential Questionnaire

Include a spouses information?*
- Yes
- No
Your Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone
Fax
Email
Birthdate*
MM slash DD slash YYYY

Spouses Information
Spouses Name
First Last
Spouses Address
Street Address Address Line 2 City State ZIP Code
Spouses Home Phone
Spouses Work Phone
Spouses Cell Phone
Spouses Fax
Spouses Email
Spouses Birthdate
MM slash DD slash YYYY

Beneficiaries
Click on the "+" button to add more information
Beneficiary
Name Relationship Date of Birth Dependent? Resides? (City & State)

Work Information
Employer
Title/Job
Number of years with this employer?
Anticipated employment changes?
Age at which you plan to retire?
Annual Income:
Bonus/Commissions
Other Earned Income
Description Amount
TOTAL (Current Year) =

Spouses Work Information
Spouses Employer
Spouses Title/Job
Number of years with this employer?
Anticipated employment changes?
Age at which you plan to retire?
Spouses Annual Income
Spouses Bonus/Commissions
Spouses Other Earned Income
Description Amount
TOTAL (Current Year) =

Retirement Plans
Current balance in 401(k), 403(b), 457, TSP, SEP, SIMPLE, etc.
Current Amount Deferred Annually
Company Match Annually

Spouses Retirement Plans
Current balance in 401(k), 403(b), 457, TSP, SEP, SIMPLE, etc.
Current Amount Deferred Annually
Company Match Annually
Please provide a brief description of the issues you for which you are seeking counsel.
Who prepares your tax return?

Indicate which of the following statements summarize your attitudes or beliefs using a scale of 1-5.
1 being most true and 5 least true
I would rather work longer than reduce my standard of living in retirement.
Please enter a number from 1 to 5.
I feel that I/we can reduce our current living expenses to save more for the future if needed.
Please enter a number from 1 to 5.
I am more concerned about protecting my assets than about growth.
Please enter a number from 1 to 5.
I prefer mutual funds over individual stocks and bonds.
Please enter a number from 1 to 5.
I am comfortable with investments that promise slow, long term appreciation and growth.
Please enter a number from 1 to 5.
I don’t brood over bad investment decisions I’ve made.
Please enter a number from 1 to 5.
I feel comfortable with aggressive growth investments.
Please enter a number from 1 to 5.
I don’t like surprises.
Please enter a number from 1 to 5.
I am optimistic about my financial future.
Please enter a number from 1 to 5.
My immediate concern is for income rather than growth opportunities.
Please enter a number from 1 to 5.
I am a risk taker.
Please enter a number from 1 to 5.
I make investment decisions comfortably and quickly.
Please enter a number from 1 to 5.
I like predictability and routine in my daily life.
Please enter a number from 1 to 5.
I need to focus my investment efforts on building cash reserves.
Please enter a number from 1 to 5.
I prefer predictable, steady return on my investments, even if the return is low.
Please enter a number from 1 to 5.
How were your current investment assets selected?
If you have worked with a financial advisor in the past, please describe the nature of the relationship in terms of compensation method, frequency of interaction, and degree of your satisfaction.

Advisor Relationships - Satisfaction Rating
Where applicable, please rate your working relationships with each of the following advisors. 1 being dissatisfied and 5 being very satisfied
Financial Advisor
Please enter a number from 1 to 5.
Accountant
Please enter a number from 1 to 5.
Tax Preparer
Please enter a number from 1 to 5.
Attorney
Please enter a number from 1 to 5.
Insurance Agent (1)
Please enter a number from 1 to 5.
Insurance Agent (2)
Please enter a number from 1 to 5.

Life Insurance
Company
Issue Date
MM slash DD slash YYYY
Death Benefit
Length of Term
Underwriting Class
Annual Premium

Spouses Life Insurance
Company
Issue Date
MM slash DD slash YYYY
Death Benefit
Length of Term
Underwriting Class
Annual Premium

Long Term Care Insurance
Company
Issue Date
MM slash DD slash YYYY
Monthly Benefit
Length of Coverage
Underwriting Class

Spouses Long Term Care Insurance
Company
Issue Date
MM slash DD slash YYYY
Monthly Benefit
Length of Coverage
Underwriting Class

Disability Insurance
Company
Issue Date
MM slash DD slash YYYY
Monthly Benefit
Length of Coverage
Occupation Class

Spouses Disability Insurance
Company
Issue Date
MM slash DD slash YYYY
Monthly Benefit
Length of Coverage
Occupation Class

Assets
Bank Accounts
Bank Name Type (checking, Savings, money market) Account Owner Average Value
Retirement Accounts
Type (IRA, Roth, 401(k), 403(b), etc.) Account Owner Interest Rate (if CD. Fixed Ann) Company Approximate Value
College Accounts
Type (ESA. 529 UTMA, UGMA) Recipient/Child Interest Rate (CD. Fixed Ann) Company Approximate Value
Other Accounts
Type (Indiv, Joint, TOD, etc.) Recipient/Child Interest Rate (CD. Fixed Ann) Company Approximate Value
Please list below and estimate a value for any other investment assets not appearing on the list or the statements provided:

Personal Property
Primary Residence Estimated Value
Furnishings (Liquidation Value) Estimated Value
Vehicle
Type Estimated Value
Other
Type Estimated Value

Liabilities
Mortgages
Description Interest Rate (%) Average Monthly Payment Current Balance
Auto
Description Interest Rate (%) Average Monthly Payment Current Balance
School
Description Interest Rate (%) Average Monthly Payment Current Balance
Business
Description Interest Rate (%) Average Monthly Payment Current Balance
Personal
Description Interest Rate (%) Average Monthly Payment Current Balance
Other
Description Interest Rate (%) Average Monthly Payment Current Balance
Have you received a copy of your credit report recently?

These items may be needed, should you choose to engage our services:
- Prior Year Tax Return
- Paycheck Stubs
- Brokerage Account Statements
- Mutual Fund Account Statements
- Trust Account Statements
- Employee Benefits Booklet
- Retirement Plan Account Statements
- Divorce Decrees
- Loan Documents
- Insurance Policies
- POA Documents
- Trust Documents
Thank you for your interest in Vision Financial Advisory Corporation, PC! Please complete and return the Confidential Questionnaire email to dawn.phillips@visionfinancialpc.com or return by mail to Vision Financial Advisory Corp, PC at 5787 Balsam Dr., Hudsonville, MI 49426

Step 1 of 20

Your Information

Spouses Information

Beneficiaries

Work Information

Spouses Work Information

Retirement Plans

Spouses Retirement Plans

Do you have the following estate planning documents?

Indicate which of the following statements summarize your attitudes or beliefs using a scale of 1-5.

Advisor Relationships - Satisfaction Rating

Life Insurance

Spouses Life Insurance

Long Term Care Insurance

Spouses Long Term Care Insurance

Disability Insurance

Spouses Disability Insurance

Assets

Personal Property

Liabilities

These items may be needed, should you choose to engage our services:

Name	Relationship	Date of Birth	Dependent?	Resides? (City & State)

Bank Name	Type (checking, Savings, money market)	Account Owner	Average Value

Type (IRA, Roth, 401(k), 403(b), etc.)	Account Owner	Interest Rate (if CD. Fixed Ann)	Company	Approximate Value

Type (ESA. 529 UTMA, UGMA)	Recipient/Child	Interest Rate (CD. Fixed Ann)	Company	Approximate Value

Type (Indiv, Joint, TOD, etc.)	Recipient/Child	Interest Rate (CD. Fixed Ann)	Company	Approximate Value

Description	Interest Rate (%)	Average Monthly Payment	Current Balance

Description	Amount

Description	Amount