Social Security Strategy Session
Name
First Name
Last Name
Spouse Name
First Name
Last Name
Your DOB
-
Month
-
Day
Year
Date
Date Picker Icon
Spouse DOB
-
Month
-
Day
Year
Date
Date Picker Icon
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
Have you (and spouse if applicable) registered for an online account at
Marital Status (please check all that apply now and in the past)
Single, never been married
Married
Separated
Divorced
Widow
Back
Next
Have you and/or your spouse started collecting Social Security?
Yes (both of us)
Yes (spouse only)
Yes (self)
No not currently
No, never had
If either of you are collecting or have collected, please explain and include dates
Are you (or your spouse) disabled?
Yes (spouse only)
Yes (self)
No, not currently
No, never
Do you have any disabled children former spouse, or other family members drawing off of your Social Security record? (if yes please explain)
What questions do you have about Social Security planning or about the SSA program?
What are your goals for your Social Security planning session?
What is your estimated Social Security benefit from your most recent Social Security Earnings Statement?
What is your estimated Social Security benefit from YOUR SPOUSE's most recent Social Security Earnings Statement?
How long do you (and spouse) expect to live?
I have additional questions/concerns or need to review my policy for:
Health Insurance
Medicare
Life Insurance
Annuities
Cancer Insurance
Dental/Vision Insurance
Long Term Care
Recovering at home Insurance
Critical Illness
Additional Questions/Concerns
If married prior, how long was the marriage?
Anticipated Household Gross Income for Current year?
Types of Income (check all that apply)
W2 Employment
Self Employment
Investments
Retirement
Alimony
Tell me about your assets and liquidity
What is your estimated net worth (from a monetary prospective)?
What are your financial objectives and personal goals?
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm