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Confidential Questionnaire

You are here: Home / Clients / Resources / Confidential Questionnaire

Confidential Questionnaire

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  • Your Information

  • Date Format: MM slash DD slash YYYY
  • Spouses Information

  • Date Format: MM slash DD slash YYYY
  • Beneficiaries

    Click on the "+" button to add more information
  • NameRelationshipDate of BirthDependent?Resides? (City & State) 
  • Work Information

  • DescriptionAmount 
  • Spouses Work Information

  • DescriptionAmount 
  • Retirement Plans

  • Spouses Retirement Plans

  • Do you have the following estate planning documents?

  • Date Format: MM slash DD slash YYYY
  • 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
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • 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
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Life Insurance

  • Date Format: MM slash DD slash YYYY
  • Spouses Life Insurance

  • Date Format: MM slash DD slash YYYY
  • Long Term Care Insurance

  • Date Format: MM slash DD slash YYYY
  • Spouses Long Term Care Insurance

  • Date Format: MM slash DD slash YYYY
  • Disability Insurance

  • Date Format: MM slash DD slash YYYY
  • Spouses Disability Insurance

  • Date Format: MM slash DD slash YYYY
  • Assets

  • Bank NameType (checking, Savings, money market)Account OwnerAverage Value 
  • Type (IRA, Roth, 401(k), 403(b), etc.)Account OwnerInterest Rate (if CD. Fixed Ann)CompanyApproximate Value 
  • Type (ESA. 529 UTMA, UGMA)Recipient/ChildInterest Rate (CD. Fixed Ann)CompanyApproximate Value 
  • Type (Indiv, Joint, TOD, etc.)Recipient/ChildInterest Rate (CD. Fixed Ann)CompanyApproximate Value 
  • Personal Property

  • TypeEstimated Value 
  • TypeEstimated Value 
  • Liabilities

  • DescriptionInterest Rate (%)Average Monthly PaymentCurrent Balance 
  • DescriptionInterest Rate (%)Average Monthly PaymentCurrent Balance 
  • DescriptionInterest Rate (%)Average Monthly PaymentCurrent Balance 
  • DescriptionInterest Rate (%)Average Monthly PaymentCurrent Balance 
  • DescriptionInterest Rate (%)Average Monthly PaymentCurrent Balance 
  • DescriptionInterest Rate (%)Average Monthly PaymentCurrent Balance 
  • 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
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Due to various state regulations and registration requirements concerning the dissemination of information regarding investment products and services, we are currently required to limit access of the following pages to individuals residing in states where we are currently registered.

Investment products and services available only to residents of: AZ, FL, IA, IL, IN, MI, MO, NC, OH, SC, TX, VA, WA, WI, WY.

Fee-based advisory services are offered through SSN Advisory, Inc., a registered investment advisor. Advisory services available only to residents of: FL, IN, MI, OH, SC, WI.

Securities offered through Securities Service Network, LLC, member FINRA/SIPC. Advisory services offered through SSN Advisory, Inc., an SEC registered investment advisory firm.

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