Federal Employee Retirement Plan Questionnaire

Name

First Name Last Name
Date of Birth *

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

Month Day Year
Date
Federal Employee Category

FERS FERS LEO FERS ATC FERS FIREFIGHTER CSRS CSRS LEO CSRS ATC CSRS FIREFIGHTER CSRS OFFSET
Agency *
Service Computation Date: Usually the date you started or the date used to calculate your retirement pension.

Month Day Year
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

BASIC Option A
FEGLI OPTION B

1X 2X 3X 4X 5X
FEGLI OPTION C

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

Will Living Trust Power of Attorney Living Will Health Care Proxy All of the Above None of the Above
Notes and Additional Information
Securities and Advisor Services offered through Silver Oak Securities, Inc.

Member FINRA / SIPC

Hearn Wealth Management and Silver Oak Securities Inc are not affiliated/separate entities.

Martin Hearn Investment Advisor Representative

DBA Hearn Wealth Management LLC
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