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Basic Questions for Retirement Income Planning
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* Indicates required question
Email
*
Your email
First Name, Middle, Last
*
Your answer
Phone number
*
Your answer
Address
*
Enter your Street Address
Your answer
City
*
Enter the City or Town
Your answer
State
*
Enter the State
Your answer
Zip
*
Enter Your Zip Code
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Current Income: All Sources
*
Provide your Pretax Income (Gross Income)
Option 1
Projected Retirement Date
*
MM
/
DD
/
YYYY
What Are Your Monthly Expenses?
*
Enter the total amount to pay your bills each month, including Rent/Mortgage, Credit Card Bill, Insurance, Utilities, Food, Transportation, Entertainment/Vacation and ANYTHING ELSE you spend money on
Your answer
Pension Amount (Estimated).
*
Enter estimated Pension - If you wont Get one, enter "0."
Your answer
Assets: Cash, Checking, Savings
*
Enter the Amount of Cash Equivalents, such as Checking, Savings, Short Term CDs
Your answer
Assets: Retirement Plans
*
Enter the total amount of 401k, 403b, 457 Retirement Plans or Annuities - if none, enter "0."
Your answer
IRAs
*
Enter the total amount of IRA's. If none, enter "0."
Your answer
Assets: Investments
*
Any other investment, Stocks, Bonds, Long-Term CDs, Mutual Funds
Your answer
Debts: Mortgage
*
Enter The Amount of Mortgage, If Any (If you don't have a mortgage, enter "0.")
Your answer
Life Insurance
*
Enter total amount of current life insurance coverage. If none, enter "0."
Your answer
Other Debts
*
Total Other Debts such as Credit Cards, Car Loans, Student Loans, ETC - If none, enter "0."
Your answer
Height: Feet/Inches
*
Feet and Inches
Your answer
Weight
*
Your answer
Zip Code
*
Your answer
Do You Use Nicotine Products?
*
Yes
No
Check any health events / conditions that apply to you
*
AFIB
Congestive Heart Failure
Stroke
Insulin dependent Diabetes
COPD
Angina
Cancer
Hepatitis Type-C
Kidney Disease
Lupus
Dialysis
Wheelchair Use
HIV
None of the Above
Required
If you checked any of the conditions other than "None of the Above" please enter the date (Year and Month) and Current Treatment - If any.
Your answer
Are you taking any doctor prescribed medications?
*
Yes
No
If you answered "Yes" to the above question, please list name and frequency
Your answer
Is there anything important that was not asked in the above questions? Feel free to write anything. THANK YOU VERY MUCH!
Your answer
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