Federal Employee Retirement Plan Questionnaire

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
City
State
ZIP Code*
Best Phone Number*
No Work Numbers Please
Email*
Personal not work
Name Spouse
Spouse Date of Birth

MonthDayYear
Date
Federal Employee Category*

FERSFERS LEOFERS ATCFERS FIREFIGHTERCSRSCSRS LEOCSRS ATCCSRS FIREFIGHTERCSRS OFFSET
Agency
Service Computation Date: Usually the date you started or the date used to calculate your retirement pension.*

MonthDayYear
Date
Annual Leave Hours*
Estimated Retirement Age*
Gross Pay per pay period*
Number of pay periods*
TSP Balance Pre Tax
TSP Contribution %*
TSP Roth Balance*
TSP Roth Contribution %*
Monthly Social Security Payment @ 62 *
Monthly Social Security Payment @ Full Retirement Age
FEGLI

BASICOption A
FEGLI OPTION B

1X2X3X4X5X
FEGLI OPTION C

Option 1Option 2Option 3Option 4Option 5
Health Insurance Premium
Estimated Income Need
Estate Planning*

WillLiving TrustPower of AttorneyLiving WillHealth Care ProxyAll of the AboveNone of the Above
Notes and Additional Information
Securities and Advisor Services offered through Silver Oak Securities, Inc. Member FINRA / SIPCHearn Wealth Management and Silver Oak Securities Inc are not affiliated/separate entities. Martin Hearn Investment Advisor RepresentativeDBA Hearn Wealth Management LLC Call us today at:(901)473-9379
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