Retirement Income Solutions for Women (RIS) Application

Retirement Income Solutions for Women (RIS) Application
Name *

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home

Area Code Phone Number
Cell

Area Code Phone Number
Work

Area Code Phone Number
E-mail *
Marital Status *

Single Married Divorced Separated Widowed
Age *

45-47 48-50 51-55 56-61 62-67 68-73 74+
Referral Source: How did you hear about the program? *
Current Source of Income *

Work Full Time Work Part Time Self-employed Full Time Self-employed Part Time
Other Income *

Social Security SSSI/SSDI Pension Other
What is your household income? *

Less than $28,400 $28,401 - $45,450 $45,451 - $51,950 $51,951 - $58,540 $58,451 - $64,900 $64,901 - $83,250 $83,251 or more
Family household size (include self) *

1 2 3 4 5 6 7 8
HOUSEHOLD NET ASSETS (exclusive of home and vehicles)
Please indicate approximate value of investments such as savings, IRA, 401K, stocks, bonds, mutual funds (may provide later if preferred) *
SELF-EMPLOYMENT: If you are interested in Self-Employment to supplement retirement income, send a separate shees describing the business you want to start and related skills and experience and/or include resume.
EMPLOYMENT: If you want to secure employment to supplement retirement income, please send a separate sheet listing employment history and/or resume.
RETIREMENT STATUS: Are you retired? *

Yes No
IF YES, when did you retire? *
Describe your retirement goals and interest in attending the Retirement Income Solutions (RIS) *
ETHNIC BACKGROUND *

Hispanic African American Asian/Pacific Islander Native American Caucasian Other
PLEASE READ CAREFULLY AND SIGN BELOW.

I understand Retirement Income Solutions is primarily targeted to women with net assets up to $250K exclusive of home and vehicles and that WORC is relying on information in this application to decide o my eligibility. The information provided above is true and complete.
By submitting and dating this application form, you are consenting to submitting your Retirement Income Solutions (RIS) application and information electronically. Please check below to confirm your consent.
Date *

Month Day Year
Please check the box to confirm your submission: *

Yes, I agree.
Should be Empty:

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