Client Data Form YOUR SECURE INCOME SOURCES IN RETIREMENT YOUR RETIREMENT SAVINGS
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1 Client Data Form Why We Collect This Information This Client Data Form collects information about your age and planned retirement dates, current income, retirement savings assets, anticipated "Secure Income Sources", and anticipated retirement expenses. We use this information as the basis for providing you with Social Security benefit analysis retirement planning solutions. PRIVACY NOTICE: Information collected is for the purpose of providing retirement planning, and may be used in conjunction with the sale of offer of financial products. Information collected may be shared with Brokers Alliance, Inc, E. Palisades Boulevard, Fountain Hills, AZ 85268, for retirement planning analysis. Brokers Alliance does not share this information with other parties. How to Complete this Form Much of the information is self-explanatory, such as your age, retirement age, etc, while how to provide other information is not as self-explanatory. Specifically: YOUR SECURE INCOME SOURCES IN RETIREMENT For all entries except Social Security benefits, please provide the monthly or annual amount, pre-tax and deductions, that you anticipate receiving. Please also provide the anticipated annual increase percentage for the income stream, if any. For Social Security benefits, accuracy is very important, so please do not guess. There are only two ways to determine your future benefits - by obtaining your Annual Social Security Statement, or by using the Retirement Estimator tool - both can only be accessed at the Social Security website ( If you are unsure as to your projected benefits, please ask for our "Determining Your Social Security Benefits" booklet, which provides step-by-step, illustrated instructions. YOUR RETIREMENT SAVINGS For each account, enter the Name, Type, Value, and Annual Pre-Retirement Contribution (including employer match). At the "Protected From Market Loss" column, indicate either Yes or No for each account. Enter "Yes" only if the account is held in a financial vehicle providing a guarantee that the balance or value will not decline due to financial market declines (ie stock market decline). Your Anticipated FOUNDATION EXPENSES in Retirement and Your Anticipated DISCRETIONARY EXPENSES in Retirement For both Foundation Expenses and Discretionary Expenses, enter the known or anticipated expense. For each expense, there is the option to enter either a Monthly or Annual amount; you need only enter one or the other. You also have the option for entering the inflation rate for each itemized expense; please do so if you want us to use a specific rate of inflation for that expense, otherwise we will assign the inflation rate. The Retirement Analysis and Forecast process is not intended as tax-planning. You should consult a qualified tax advisor for tax planning analysis and advice.
2 Date: Name: CLIENTS Client 1 Client 2 Name: Current Age: DOB: Current Age: DOB: Retirement Age: Year: Retirement Age: Year: Annual Income Pre-Retirement Client Relationship: Annual Income Pre-Retirement YOUR ESTIMATED EFFECTIVE INCOME TAX RATE Your Effective Income Tax Rate is simply how much total income tax (federal and state) you pay as a percentage of your gross income. For example, if you earned gross income of $100,000, and you paid total income taxes of $25,000, then your Effective Tax Rate is 25% ($25,000 $100,000). Your estimated Effective Tax Rate is used for income and tax estimates, but as it varies yearly based upon a variety of factors it cannot be warranted. Effective Income Tax Rate to be used: YOUR PROJECTED SOCIAL SECURITY BENEFITS Client 1 Client 2 Benefit at Age 62: Benefit at NRA: Benefit at Age 70: Life Expectancy: Start Year or Age End Year or Age Benefit at Age 62: Benefit at NRA: Benefit at Age 70: Life Expectancy: YOUR SECURE INCOME SOURCES IN RETIREMENT A "Secure Income Source" is any income during retirement that you anticipate receiving that is not related to nor dependent upon your cash/cash equivalent retirement savings; for example, pensions and rental income. Source Pension Pension Recipient Monthly Amount (Pre-Tax) Assumed Annual Increase % Regarding Your Secure Income Sources:
3 YOUR RETIREMENT SAVINGS Your Tax-Qualified Retirement Accounts Tax-Qualified Retirement Accounts are accounts such as Individual Retirement Arrangements (IRA), 401(k), 403(b), 457, Thrift Savings Accounts, or similar accounts in which you saved on a pre-tax basis. Tax-Qualified accounts are subject to Required Minimum Distributions beginning at age 70½, and can only be individually-owned. If you list an Inherited IRA, at the Additional Information section please provide the age at which the person from whom you inherited the IRA died, and their date of birth (this information is needed to calculated Required Distributions). Client 1: Account Name Type Tax-Qualified Retirement Accounts Value Annual Contribution $ Your Employer Savings Match Protected from Mkt Loss? Pre- Retirement Anticipated % Return Conservative; Applied to All Accounts Client 2: Account Name Type Value Tax-Qualified Retirement Accounts Annual Contribution $ Your Savings Employer Match Protected from Mkt Loss? Pre-Retirement Rate Shown above will be applied to all accounts. Your Savings Cash or cash-equivalent retirement savings not held in Tax-Qualified Retirement Accounts, such as brokerage assets, bank savings, Certificates of Deposit, etc. List only accounts that you want considered for use as retirement income. Do not list real estate values, home equity, or other non-cash/cash-equivalent assets. Account Name Type Value Annual Contribution $ Protected from Mkt Loss? Pre-Retirement Rate Shown above will be applied to all accounts. Regarding Your Retirement Savings:
4 FOOD / CLOTHING Groceries Drugstore (Non Rx) Clothing Your Anticipated FOUNDATION EXPENSES in Retirement "Foundation Expenses" provide for your retirement income "needs." TRANSPORTATION Auto Loan/Lease 1 MAIN RESIDENCE Mortgage or Rent Insurance Taxes Auto Loan/Lease 2 When will Auto Loan 1 be paid-off? Are Insurance & Taxes Included in the When will Auto Loan 2 be paid-off? Mortgage Payment? How often to replace cars in retirement? When will the mortgage be paid-off? Add'l Trans Exp Add'l Residence Exp Gasoline HOA Fees Auto Insurance Utilities Maintenance TV and Internet Registration Fees NA Telephone Cell Telephone Home Maintenance Yard / Pool Service MEDICAL Health Insurance Dental Insurance Medicare Prem Medicare Prem Medicare Supp Medicare Supp Medicare Rx Medicare Rx Rx Out-of-Pocket Out-of-Pocket INSURANCE Life Insurance Long-Term Care Umbrella Policy Critical Illness MISCELLANEOUS :
5 OTHER RESIDENCE Mortgage or Rent Insurance Taxes Are Insurance & Taxes Included in the Mortgage Payment? When will the mortgage be paid-off? Add'l Residence Exp HOA Fees Utilities TV and Internet Telephone Your Anticipated DISCRETIONARY EXPENSES in Retirement Cell Telephone Home Maintenance Yard / Pool Service ENTERTAINMENT Restaurants Hobbies Movies, Sports, Etc Club Dues "Discretionary Expenses" provide for your retirement income "desires." TRAVEL Air Tickets Gasoline Hotels Dining Shopping Activities At what age should travel be reduced? If travel reduced, by what percentage? MISCELLANEOUS Church/Charity Family Assistance Gifts RECREATION Boat/RV Loan/Lease When will Boat/RV loan be paid-off? Add'l Recreation Exp Boat/RV Insurance Boat/RV Gasoline Boat/RV Maintenance Boat/RV Registration
6 OTHER RETIREMENT PLANNING INFORMATION LIFE INSURANCE Insured Beneficiary Death Benefit Type Cash Value LONG-TERM CARE INSURANCE Insured Type (Traditional Policy, Life Insurance Rider, Annuity Benefit) Do you have will? Do you have medical and other Powers of Attorney? Have you established a Trust for your Estate? Do you have any special-needs dependents? ADDITIONAL INFORMATION & NOTES
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