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									                     Vineyard Columbus Financial Counseling Ministry
A personal note about financial counseling…
You are to be complemented for taking the important step to seek counsel regarding your finances. Finances are
one of the biggest parts of life, and the Bible says that “Plans fail for lack of counsel, but with many advisers they
succeed.” (Proverbs 15:22), so you are very wise to seek counsel regarding this area.

The vision of counseling is to help people have a proper Biblical understanding and apply it practicall y to
personal management of their finances. Following God's plan helps us to be better stewards, less burdened by
debt, and better marriage partners. It also helps us ent er into a closer relationship with Jesus and contribute to
Kingdom activities. God wants you to have financial freedom whether in crisis, great abundance or somewhere
in between.
Don’t delay
Many people are hesitant about financial counseling, either because of the time to fill out this questionnaire,
embarrassment, or feelings of defeat or hopelessness. Often people put off dealing with it now becaus e they
think it is too hard or painful and believe things will just get better on their own. In reality financial circumstances
usually continue to deteriorate, especially given the recession. Sooner is better bec ause making good decisions
now helps people from getting in deeper financial straights, and avoiding bad financial decisions that may be
more difficult to unwind later.

We understand the needs, difficulties and importance of personal financial management, and took this into
consideration when we created our counseling program.
Our philosophy: Grace Filled Financial Counseling
      Non-judgmental and objective and provide an outside perspective. Provide encouragement, hope, prayer,
       and biblical wisdom
      Keep information confidential and help any one regardless of income and charge no fees
      We don’t make decisions for the couns elee, sell products, nor provide professional services (e.g., tax,
       legal, accounting) and we don’t provide financial assistance. Coaching is gladly provided to anyone,
       church attendance or membership is not required
Our process
  Complete this questionnaire and bring it with you. It would be helpful if you could provide a copy in advanc e
   (drop off, email, or fax (614) 890-5056)
  If married or engaged, we would like both people to come together if possible
  Help you construct and follow a plan that leads to financial freedom, as well as answer questions about
   various financial topics, provide accountability (if desired), and ex plore practical & spiritual solutions
  1 Meeting: Review completed Questionnaire P art I (complete Part II if your situation is urgent or if you are in
   crisis), discuss your questions and your situation- and pray with you. At the conclusion of the meeting (or by
   email) the coach will provide an initial brief overview and outline of the steps to complet e desired results
  2nd and ongoing m eetings if desired: Review completed Financial Information Questionnaire Part II. Discuss
   and handout assignments, assist with items, accountability, and track progress
Contact & Other Information
Visit http://vineyardcolumbus.org/need-help/financial-freedom/ for information about resources, seminars, or for
an appointment for financial counseling call/email Kent Irwin 259-5505, kent.irwin@vineyardcolumbus.org.
Questionnaire Instructions
We ask a lot of questions because life and finances are complicated- sometimes we need to see the whole
picture to help you the best we can. This may seem like a big task (but it will go fairly quickly), but will also help
you in getting organized and collecting your thoughts. Do not worry if you are not able to answer every question,
just do your best, some information can be provided later as needed. All information is private and confidential.
By completing this form, I am requesting non-professional financial counseling from the financial ministry and programs of Vineyard Church of
Columbus and/or Vineyard Community Center (collectively, “Vineyard”), and I understand that the financial counseling I receive (a) will be
provided by either a Vineyard paid staff member or volunteer who has been trained to serve in the Vineyard ministry or program but who is not
otherwise trained, licensed, or in any way formally qualified or authorized as a financial planner, investment advisor, accountant, or lawyer, and
(b) will be neither legal, tax, investment, nor professional financial advice.
In consideration of the financial counseling being provided to me by Vineyard (the “Services”), I (for myself and my heirs, assigns,
representatives, and other successors-in-interest (collectively, the “Releasors”)) hereby waive and release Vineyard Church of Columbus and
Vineyard Community Center and their respective directors, officers, employees, volunteers, and agents from all liability for any injury, damage, or
loss incurred or suffered by any Releasor resulting directly or indirectly from the Services.
                                                   Keep this page for your records
                  Part 1. Confidential Financial Coaching Questionnaire

A1. I am requesting counseling for
  Category                                                  Description                                                              X
  Crisis           Very concerned about financial condition, need immediat e direction to avert disaster
  Skills           I desire some practical pers onal finance knowledge and spending/budgeting skills

  Questions        I have financial questions
  Change           I would like long-term change in my personal finances and/or to have financial freedom
  Spiritual        I desire God’s direction and wisdom regarding finances

  I’ve read disclaimer on cover page

A2. General information
  Your Name


  Home Phone                                                            Work Phone

  Cell Phone                                                                     Email

  Preferred Contact             Work                  Cell                 Home                   Day           E ve

   Age:                   Employer:                               Occupation:                           Hourly? Hours per week:

  Spouse                                                           Work Phone

  Cell Phone                                                               Email

  Preferred Contact              Work                      Cell                 Home                    Day             E ve

   Age:                 Employer:                        Occupation:                                Hourly? Hours per week:
  Vineyard Cols Info:         Member                          Attendee                  Small Group               Volunteer

  A3. Other information that may be important in planning
  Single                    Engaged                    Married             Separated              Divorced       Widowed

     U.S. Citizen?            Yes / No                             If Divorce              Ye s                 Comment
  Children’s ages:
  Do you plan to move in the near future? ...........................................
  Do you plan to change occupations soon? ........................................
  Are you planning to have children or change marital status?.............
  Do you plan to seek additional education? …………………………...
  A4. Meeting Checklist: Things you might need to bring                                                                              
  Two Recent Payroll Stubs (for budget counseling).…………………….…………………………………………...
  Mortgage statement (if mortgage or loan modification questions)…………………………………………………
  Note pad and pen (for you to take notes )…..………………………………………………………………………...
  Any important records you have questions about (see I C.4)
  Credit report if you have questions about debt (www.annualcreditreport.com for a free report)………............

                                                                       2                                                   Confidential
B. How can we help?

B1. My Specific Goals of financial counseling
Overall                                                              Ye s? X   comment

I am doing ok ay financially, but want to discuss…
I have specific financial questions and/or need direction with…
I am having financial difficulty and need financial counseling


Lessen the financial impact of a rec ent financial setback such as
job loss or design a financial crisis recovery plan

Develop/follow a budget/spending plan

Reduce unnecessary expenditures

Balance checkbook

Develop a debt reduction plan

Organize Personal Finances

Save money for emergencies

Increase financial literacy

Direction with creditor, credit, or foreclosure issues

I have specific questions about…
I want to meet: 1. Once  or a few times  for the (above)
  2. On a ongoing basis for accountability and to stay on track 
If meeting more than once I commit to progressing on my plan
and will complete homework assignments that I agree to
Save and invest for retirement, college education

Learn computer skills (e.g., online banking, Quicken, Excel)

B2. I need to know more God’s perspective on
Subject                                                              Ye s? X   Comment

Plans for me in terms of money



Wealth, Prosperity

Cont entment

Godly decision making


                                                         3                               Confidential
C. Tell us about Your Current Situation

C1. My present financial situation
Category                                Description (indicate only 1 category)                                  X
1 Surplus         Income exceeds expenses, good savings, low debt. Living off of assets
2 Solid           Income exceeds expenses good margin, good savings/investments, no/low debt
3 Stable          Income exceeds expenses okay margin, okay in vestments, maybe high debt
4 Marginal        Expenses almost exceed earned income, may have some savings & high debt
5 Struggling      Expenses far exceeding earned income, depleting res erves, and may have high debt
6 Crisis          No income and/or ex penses far exceeding earned income, and may have high debt

C2. Challenges
Issue                                          Yes? X                             Comment
Lost employment
High or over use of debt
Behind on bills
Home in Foreclosure or worried about
Near or in bankruptcy
Divorce or separation
Lack of health insurance or underinsured
Victim of identity theft?
Had checks, debit/credit cards, stolen?
Victim of predatory lending?
Self-employed business not doing well
Spouses not seeing eye to eye on money
Made purchases I could not afford
Shopping addiction or Depression spending
I am helping someone else financially
Checking account overdraw charges

C3. I have done the following to improve my situation
Issue                                          Yes? X                             Comment
Some attempt to create a budget
Sold assets
Downsized lifestyle
Quit or cut back on some ex penses                          e.g., tobacco, hobby, eating out
Studied financial issues
Considered/obtained second job
Become a more frugal shopper
Cont acted Vineyard’s Recession Team
Talked to Vineyard’s career specialist
I’ve taken financial courses                                e.g., Crown, Ramsey, Good $ense
Discretionary spending limit (if married)?                  e.g., call other spous e prior to spending?

                                                        4                                                 Confidential
C4. I have specific questions about :                          Yes? X     Bring to the meeting if questions
Payroll Stubs
Insuranc e Policies
Credit Card, Mortgage, Lease and any Loan Statements
Individual Income Tax Returns
Investment, Savings and Checking Account Statements
Employee Handbook describing all benefits
Credit Report

C5. I am thankful for (you may want to include giftings and talents, growth lessons)

Part II. Various Personal Finance Information
D.1 Organization & Budgeting       Yes? X Comment
All financial records organiz ed?                        Kept up-t o-date in one file?
I have a copy of your credit report(s)?                  If No, go to annualcreditreport.com (free)
I know your credit rating number?                        Indicate rating # or good, ok, poor?
I balance checking accounts monthly
I have a budget/spending plan?                           If yes, how do you track actual income and expenses vs.
------------------------------------------------------   your budget?
If yes, I follow it?
I pay bills online?
I use computerized budgeting software?                   (e.g., Quicken, Mint.com
I’m able to use Spread Sheet software?                   (e.g., Excel)
I do my own taxes?
I am a saver typically (vs. spender)                     If married, indicate separately
I dedicate time each week to pay bills?                  If married indicate who pays
I have Financial/ Legal/ Tax etc. advisors?

 D.2 Debt remediation and assistance experience
Creditors are now calling/mailing me?                    If yes, please describe:
Collectors/attorneys calling/mailing?                    Specify if letters from attorneys/law firms
Legal actions been filed against me                      e.g., foreclosure/delinquent debt?:
I (we/spouse) declared bankruptcy?                       If yes, indicate year, type, and if discharged?
I’ve sought assistance from a Credit                     For example: CCCS.com
Counseling Company                                       If yes, indicate firm, year, and provide detail
I’ve contacted creditors ?                               to make arrangements for late payments
Engaged an attorney for debt relief?
Investigat ed foreclosure assistance?
Investigat ed loan modification?
Receiving any government benefits?                       If yes, which?
Using Section 8 housing?
Receiving any disability benefits?                       If yes, which?
Exploring government benefits?                           If yes, please describe:
Cons ulted with “The Benefit Bank?”                      If yes, please describe:
Receiving help from friends/ family?

                                                         5                                                 Confidential
E. Information about the Things you Own and Taxes
E1. Liquid Assets (easily convertible to cash)
               Savings                                         Amount                                       Comment
            Checking/Cash                  $
    CDs/Savings/Money Market               $
                 Other:                    $

            Investments                       Owner      Current Estimated Value              Recent Withdrawals?                Other

 Retirement e.g., 401(k), 403b                           $
         Circle: IRAs, Annuities                         $
                                                                                                                             FSA, HSA,
Healt h Savings Account:                                 $                                                                   MSA?

 Stocks, Bonds, Mutual Funds                             $
     Other: e.g. antiques, coins                         $
          Debts owed to you:                             $

                                          Behind on mortgage or real
E2. Home Information                      estate Taxes? Ye s/No
                                                                                  Current Home Value             $

    Mortgage        To Whom Owed           Current Amount Owed        Monthly Pa yment       Interest Rate %           Fixed or Var. %

1 Mortgage          $                     $                           $                                     %

2nd Mortgage        $                     $                           $                                     %

E3. Use Assets (e.g., cars, boats, motorcycles, other personal property)
  Describe Item        Fair Market Value           Description                                                    Comment
(e.g., car, boat, motorcycle)          (if car- see kbb.com)          (year, m ake, model, miles)

1 Automobile #1                    $

2 Automobile #2                    $

3                                  $

                                                                                                    Comment - If no, indicate type,
E4. Tax info                                                                    Yes        No
                                                                                                    year, and details:
Are all federal, state, local & business- taxes filed & paid?                                       Owe?
Are there any outstanding tax issues?
Self employed - paying quarterly est.?
Has your home been re-appraised for real estate taxes?

Yearly Info These may need to be incorporated into Tax expenses as an adjustment
Refunds Received or Due you                                                     Tax Year        Federal        State      City     Local
If you received one or more inc ome tax refunds and/or have                     2009
filed and expect to receive one or more, please indicate amount                 2008
Taxes Owed and had to pay/will pay                                              2009
If you owed one or more income taxes when you filed, and/or
expect to owe the next time you file, please indicate amount

                                                                  6                                                       Confidential
F. Information about the Money You Owe (Debt)

     Enter all non-mortgage debt information (e.g., auto loans, credit cards, other unpaid debts)
                        Lender           Balance:
                                                         Required :        Monthly      %                         Remaining:
                        Name:            Remaining                                     Loan        Period:
                                                         Minimum          Payment                               # of payments
#    Loan Type            e.g.,           Amount                                        Int.       Orig. # of
                                                          Monthly         (if paying                             left (until pay
                      1st National         Owed                                        Rate         Months
                                                          Payment         more than                                    off)          Other Vital
                                                                           current)                                                 Information
     CC = C. Card                                                                                                                   OK = Current
      SL = Student                                                                                                                  L = Past Due
       A = Auto                                                                                                                     D = Deferred
      M = Medical                                                                                                                   U = Unknow n
     T = Back Taxes                                                                                                                C = Collections
        O = Other                                                                                                                  N = Negotiating

1                                    $               $                $                        %

2                                    $               $                $                        %

3                                    $               $                $                        %

4                                    $               $                $                        %

5                                    $               $                $                        %

6                                    $               $                $                        %

7                                    $               $                $                        %

8                                    $               $                $                        %

9                                    $               $                $                        %

10                                   $               $                $                        %

11      TOTAL                        $               $                $

                                                                      7                                                    Confidential
12    Without                  $              $            $
     Auto Loans

G. Income: Information about the Money You Receive
Complete the following sheets here or if you are familiar with Excel, complete the Excel version The
Excel version can be emailed to you or you can access it at http://vineyardcolumbus.or g/need-help/spending-plan/ .
See most recent Payroll Stubs. If self employed provide/estimate income, expenses or profit and loss.
Earned Income: If paid biweekly – every 2 weeks-- please use this formula to calculate your average monthly
income: (gr oss pay) X 26 /12.

                     A. GROSS Projected Monthly Income: Salary

Income 1:
Income 2:
A. Total salar ies
                           B. Deductions from paycheck

Taxes (all)
Insurance (all payroll deductions)
Other taxes
FICA, FUTA, Medicare
H S A, Flexible Spending
Retirement (payroll deducted)
B. Total deduct ions
                                   C. Other Income

Unemployment Compensation
Social Security or other Gov't Income
Disability Income
Self employment income
Food Stamps
Other Income (e.g., child support, alimony)
C. Total Other Income
D. NET Income: (A + C) - B

1. Tithe and Offering (local)                        Estimated           Proposed

Vineyard Columbus (other donation #12.)
Percentage (based on gross income)

Self Employment Taxes set aside

2. Net Spendable Income                              Estimated           Proposed
Total net income minus tithe &
                                                           8                                        Confidential
minus self employment income =

H. Information about the Money You Spend - Monthly
 Est imated = your current expected monthly amount.     Proposed = new number after discussing with counselor
 Loan pay off information from page 7.

 3. Housing                                     Estimated            Proposed           Loan Pay Off
 Mortgage or rent
 Second mortgage or rent
 Homeowners/Renters Ins (non-escrowed)
 Real estate tax (if not escrowed)
 Phone L Line (if w cable/internet see #8)
 Maintenance or repairs
 Cell Phone
 Other (e.g., homeowners/condo dues)

 4. Food                                        Estimated            Proposed
 Grocery Store (not eating out- #8) Subtotals

 5. Transportation                              Estimated            Proposed          Loan Pay Off
 Vehicle 1 payment
 Vehicle 2 payment
 Bus/Taxi Fare

 6. Insurance                                   Estimated            Proposed
 Medical (not payroll deducted)
 Disability Insurance (not payroll ded)
 Dental (not payroll deducted)
 Vision (not payroll deducted)
 Long Term Care (not payroll deducted)
 Supplemental (not payroll deducted)

                                                    9                                          Confidential

7. Debts: see F. page 7 (not auto or home)   Estimated   Proposed   Loan Pay-Off
Credit   card:
Credit   card:
Credit   card:
Credit   card:
Credit card:
Student Loan
Student Loan
Student Loan
Medical debt
IRS payment (back taxes)

8. Entertainment/Recreation                  Estimated   Proposed
Eating Out DINNER
Eating Out LUNCH
Eating Out BEVERAGE (e.g., Starbucks)
Movies (theatre, rental, pay-per-view)
Sporting events
Live theater
Health club
Cable & Internet + Phone
Other (e.g., hobby, tobacco)

9. Clothing                                  Estimated   Proposed

10. Savings (not Invest ment)                Estimated   Proposed
Bank, Credit Union, Money Mar ket Account

11. Medical Expenses                         Estimated   Proposed

Doctor Visits

                                               10                           Confidential

12. Miscellaneous                                          Estimated                Proposed
Toiletry, cosmetics (items not included in groceries)
Beauty, Barber, Nails, Tanning
Laundry, Dry cleaning
Other charitable contributions -- non-Step 2
Postage and Supplies
Pets (medical, grooming)

13. Invest ment (not savings)                              Estimated                Proposed

Regular- Non Retirement Non payroll deducted
College education

14. School, Children, Childcare                            Estimated                Proposed
Tuit ion
Materials, School fees
Sports, music lessons
Day Care, Baby Sitting
                The counselor will help you with the following, it is not necessar y for you to complete
                         Thank you for taking the time and effor t to complete this questionnaire.

                TOTAL EXPENSES                            Est imated             Proposed #1          Proposed #2
3. Housing
4. Food
5. Transportation
6. Insurance
7. Debt
8. Entertainment/Recreation
9. Clothing
10. Savings
11. Medical
12. Miscellaneous
13. Investments
14. School, Children, Childcare

                                                            11                                             Confidential

        INCOME VERSUS EXPENSES             Est imated   Proposed #1   Proposed #2
Total Net Spendable Income (all sources)
Income Less (-) Expenses

                                            12                           Confidential

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