Confidential Personal Planning

Questionnaire
Prepared for: Tim Woods

Provided by:
Mitchell Woods

Table of Contents
Personal Information ...........................2
Children ............................................2
Residence Information.........................2
Professional Advisor Information ...........2
Employment/Income Information ..........2
Financial Information...........................3
Insurance Information .........................3
Planning Priorities ...............................3
Important Information.........................4

Confidential Personal Planning Questionnaire

Personal Information
Name:
Date of Birth:
E-Mail Address:
Height/Weight:
Tobacco Use?:
Hazardous
Occupation?:

Client
______________________
Tim Woods
8
4
1950
______/______/________
woods@lsu.edu
______________________
____ft____inches/____lbs.
5
8
200
__Yes __ No ___________
__Yes __ No ___________
______________________
Financial Advisor

Spouse
______________________
Threasa Woods
8
8
1950
______/______/________
woods2@lsu.edu
______________________
____ft____inches/____lbs.
5
6
200
__Yes __ No ___________
__Yes __ No ___________
______________________
Nurse

Children
Name:
Date of Birth:

Child 1
_________
Mitchell Woods
__/__/____
10 20 1994

Child 2
_________
Lindsey Woods
__/__/____
04 04 1991

Child 3
_________
__/__/____

Child 4
_________
__/__/____

Residence information
Street Address:
__________________________________________________
1234
Happy Street
City, State, Zip:
__________________________________________________
Baton
Rouge, LA 70820
Home Phone No:
__________________
Cell Phone No: ___________________
225-555-5555
N/A
Own?
Mortgage Payment: _________
Mortgage
Balance:
___________
$0
$0
Rent?
Monthly Rent: ___________

Professional Advisor Information

Clients Will:
Spouses Will:
Attorneys Name:
Accountants Name:

Date __________
Type __________________________
1/1/1990
Reciprocal
Date __________
Type
__________________________
1/1/1990
Reciprocal
_________________________
Phone No.: _____________
Mr. Bob
337-555-0300
_________________________
Phone No.: _____________
Mr. Otray
337-555-4400

Employment/Income Information
Occupation:
Employer:
Business Street
Address:
City, State, Zip:
Phone Number:
Fax Number:
E-Mail Address:
Annual Income:
Other Income:

Client
_____________________
Financial Advisor
_____________________
Merrill Lynch
_____________________
North Main Street
_____________________
1223 North Main Street
_____________________
Baton Rouge, LA 70820
_____________________
337-555-0001
_____________________
337-555-0002
_____________________
woods@lsu.edu
_____________________
$200,000
_____________________
$15,000

Confidential Personal Planning Questionnaire

Spouse
Nurse
______________________
______________________
Lake Charles Hospital
______________________
Riverridge Drive
______________________
4455 Riverridge Drive
______________________
Baton Rouge, LA 70820
______________________
337-555-0003
______________________
337-555-0004
______________________
woods2@lsu.edu
______________________
$150,000
______________________
$120,000

Financial Information
Assets
Savings
__________
$500,000
$400,000
Investments
__________
IRA(s)
__________
$1,000,000
$250,000
Real Estate
__________
Business Interests
__________
$20,000
Personal Property
__________
$120,000
Other
__________
$10,000
$2,300,000
Total Assets
__________
Current Monthly Systematic Savings:

Liabilities
Installment Loans
Mortgage(s)
Charge Accounts
Credit Cards
Personal Notes
Business Debt
Other
Total Liabilities
$5,000
___________

____________
$1,000
$0
____________
____________
$2,000
$4,000
____________
____________
$10,000
____________
$15,000
____________
$5,000
$37,000
____________

Insurance Information
Life Insurance
Policy
Policy
Face
Annual
BeneInsured
Company
Number
Date
Amount
Premium
ficiary
__________
________
_____
________
________
_______
BlueCross
Health Service _________
200787657
01/14
$100,000
$500,000
1,000,000
__________ ________ _________ _____ ________ ________ _______
__________ ________ _________ _____ ________ ________ _______
__________ ________ _________ _____ ________ ________ _______
Long-Term Care Insurance
Policy
Policy
Daily
Benefit
Annual
Insured
Company
Number
Date
Benefit
Period
Premium
N/A
__________
________ _________ _____ ________ _______
_______
__________ ________ _________ _____ ________ _______
_______
Other Insurance
Monthly Disability Benefit:
Client ___________
Spouse ___________
Critical Illness Insurance Benefit:
Client ___________
Spouse ___________
Health Insurance:
Client __________
Spouse ___________
P&C Expiration Dates:
Auto ______
Homeowners ______
Other _______

Planning Priorities
High
Medium
Protecting Familys Lifestyle
_____
_____
Protecting Income
_____
_____
Providing Education Funds
_____
_____
Implementing Savings Plan
_____
_____
Planning for Retirement
_____
_____
Minimizing Estate Shrinkage
_____
_____
Planning for Business Continuation
_____
_____
Other: ______________________
_____
_____
How much do you feel comfortable setting aside on a monthly

Confidential Personal Planning Questionnaire

Low
_____
_____
_____
_____
_____
_____
_____
_____
basis?:

None
_____
_____
_____
_____
_____
_____
_____
_____
$10,000
_________

Important Information
This fact finder serves to help identify your financial needs and priorities and may be
used in developing proposed solutions consistent with your needs and objectives. In
completing this fact finder, you are entrusting our organization with certain personal
and confidential financial data. We recognize that our relationship with you is based on
trust and we hold ourselves to the highest standards in the safekeeping and use of your
confidential information.
The information, general principles and conclusions presented in this report are subject
to local, state and federal laws and regulations, court cases and any revisions of same.
While every care has been taken in the preparation of this report, neither VSA, L.P. nor
The National Underwriter Company is engaged in providing legal, accounting, financial
or other professional services. This report should not be used as a substitute for the
professional advice of an attorney, accountant, or other qualified professional.

VSA, LP

All rights reserved (VSA ff-01 ed. 01-12)

Confidential Personal Planning Questionnaire