Assessment Intake Form – Her Retirement

Am I Ready for Retirement? Assessment Intake Form

Your Contact Information

Your Name:

Your Phone Number:

Your E-mail address:

General Information

About You:

Your Age:

Your Approximate Annual Income:
$
Age You Plan to Retire:

About Your Spouse or Significant Other (if applicable):

Their Age:

Their Approximate Annual Income:
$
Their Age Plan to Retire:

Income Sources in Retirement:

(You can find your Social Security Income on www.ssa.gov)
Your Social Security Income at your Full Retirement Age (FRA):
$
Your Significant Other/Spouse Social Security Income at (FRA):
$
Your Pension Income at Retirement (if applicable):
$
Your Significant Other/Spouse Pension Income at Retirement:
$
Other Sources of Income at Retirement:
$

Investment Assets:

Your Investment Accounts

Tax Deferred Accounts (PreTax)

IRAs:
$
401ks/403bs/457s:
$

Tax-Free Accounts (Roth IRA)

Roth IRAs:
$
Roth 401ks/403bs/457s:
$

Non Tax-Deferred Accounts (Stocks, Mutual Funds, etc.):
$
Annuities:
$
Other Investment Accounts:
$
CDs, Money Markets, Checking, Savings:
$

Your Significant Other/Spouse's Investment Accounts (if applicable)

Tax Deferred Accounts (PreTax)

IRAs:
$
401ks/403bs/457s:
$

Tax-Free Accounts (Roth IRA)

Roth IRAs:
$
Roth 401ks/403bs/457s:
$

Non Tax-Deferred Accounts (Stocks, Mutual Funds, etc.):
$
Annuities:
$
Other Investment Accounts:
$
CDs, Money Markets, Checking, Savings:
$

Non-Investable Assets

For property please indicate current value, mortgage balance, interest rate, monthly payment, term.
Primary Residence

Other Property

Additional Notes & Details

Please add any other applicable information:

How did you hear about us?

Should you have any questions please contact Lynn Toomey at: retire@herretirement.com or at: 508.798.5115

Note: This is a secure form. Information entered is not publicly available. We do not ask for personal information such as date of birth, account details, etc.

Her Retirement