Retirement Planning Questionnaire
Personal Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Please Select
Male
Female
Transgender
Gender-neutral
Prefer not to answer
Marital Status
Please Select
Single
Married
Divorced
Widowed
Spouse Contact Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
1
Same as spouse
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Situation
Are you already retired?
Yes
No
If not, what is your current income? (annual, $)
When are you planning to retire? (year)
Include your spouse in the plan?
Yes
No
Is your spouse already retired?
Yes
No
If not, what is your spouse's current income? (annual, $)
When is your spouse planning to retire? (year)
Finance
How much of your (and your spouse's) assets in total? ($)
What will be your tax rate in later years? (%)
How much coverage do you have in your protection plan?
What level of beneficiaries will be need during retirement?
Insurance Information
Rows
Face Value
Term (months) / Type
Premium per Year
Benefit
Term Policies
Permanent Policies
Disability Insurance
Care Insurance
Legal
Have you compiled a list of contact information for your closest family?
Yes
Not yet
Have you updated your will and living will?
Yes
Not yet
Responsible person for your will and living will
First Name
Last Name
Responsible's Email
example@example.com
Responsible's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Lifestyle
Where do you plan to live during retirement?
Do you plan to finish life in home or in assisted living?
Home
Assisted living
Date
 -
Month
 -
Day
Year
Date
Signature
Submit
Should be Empty: