Full Name
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Email
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Phone
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Age
*
What state you live
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
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PA
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UT
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What’s your favorite vegetable? (Security Question)
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What would be a comfortable monthly contribution towards your tax-free retirement account?
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$100-$300
$300-$500
$500-$800
$800 or more
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What is your primary financial goal?
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Zero Risk or Exposure to Market Downturns
Guaranteed Interest Rates
Tax-Free Retirement Income
No Tax Liability on Growth
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How soon are you planning to retire?
I don't know IF I can retire
Within 10 Years
Within 20 Years
Within 30 Years
I am CURRENTLY RETIRED
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Which retirement benefit most interests you?
Zero Risk or Exposure to Market Downturns
Guaranteed Interest Rates
Tax-Free Retirement Income
Preservation of Capital
No Tax Liability on Growth
On a scale of 1-5, how serious are you about saving money for retirement?
1 (Not Serious)
2
3
4
5 (Extremely Serious)
How much do you currently have saved for retirement?
Less than $100k
$100k - $300k
$300k - $500k
More than $500k
Are you currently contributing to a 401(k)/403(b)/TSP/IRA or other employer retirement account programs?
Yes
No
How much debt do you have, including your mortgage?
Less than $100k
$100k - $300k
$300k - $500k
More than $500k
If your mortgage and all your debts were paid off, when would you retire?
Immediately
Less than 5 years
5-10 years
More than 10 years
If you had no debt, would you be able to contribute more towards your retirement?
Yes
No
What is your primary source of income?
Employed
Self-Employment
Social Security
Disability
Passive Income
Retirement Funds
Estimate your annual household income
0 - $50k
$50k - $100k
$100k - $250k
More than $250k
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