Retirement Plan Design Questionnaire

Company Name
First Name
Last Name
Address Line 1
Address Line 2
City
State	Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire Nevada New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip	-
Daytime Phone Number	-   -
Evening Phone Number	-   -
Fax Number	-   -
Email Address
Occupation
Date of Birth
Annual Earnings	$
Do you currently participate in or maintain a retirement plan? YES NO
If yes, identify the type(s) of Plan(s) and their estimated level of assets.
Current Contribution Per Year	$
How many individuals are employed by your business?
What is the name of your business?
How is it structured (sole proprietorship, corporation, etc.)?
My spouse is employed by me. YES NO
My spouse is employed at
My spouse participates in a plan at work. YES NO
My spouse's type of plan is
Please enter a rating of 1-5 for each item below based on the following scale 1=Strongly Disagree 2=Mildly Disagree 3=Neutral 4=Somewhat Agree 5=Strongly Agree
I want to maximize retirement benefits for owners/key employees.	-   1    2    3    4    5  +
I want to maximize my tax deduction.	-   1    2    3    4    5  +
I want to allow employees to save for their retirement.	-   1    2    3    4    5  +
I would offer a matching employer contribution to help employees save for their retirement.	-   1    2    3    4    5  +
Employees generally have long service with our organization.	-   1    2    3    4    5  +
I can generally produce better investment results than a professional advisor.	-   1    2    3    4    5  +
I need a better understanding of what I will have to live on at retirement.	-   1    2    3    4    5  +
If I could, I would like to deduct from my taxes:	$10,000 $30,000 over $30,000
I would like to retire in:	10Yrs. 20Yrs. Age 65 Age
The best time to phone me for the initial consultation is:
An alternate time to phone me for the initial consultation is: