Roth Conversion + Roth Conversion Alternative
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Managing Director's Name
*
First
Last
Managing Director's Email
*
IRA Owner's Name (your client)
*
First
Last
IRA Owner's City & State of Residence
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IRA Owner's Age (closest) or Date of Birth
*
IRA Owner's Projected Health Rating
*
Non-Smoker Best of Class
Non-Smoker Preferred
Non-Smoker Standard
Non-Smoker Top Rated
Smoker Preferred
Smoker Standard
Is the IRA Owner a US Citizen?
*
Yes
No
IRA Owner's Biological Gender At Birth
*
Male
Female
IRA Owner's Email
*
IRA Owner's Phone Number
*
IRA Owner's Employer
*
$ IRA Owner's Annual Income USD
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$ Total Household Liquid Net Worth (not including 401K or IRA)
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$ Total IRA & 401(k) Assets
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Desired income for lifestyle?
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What percentage of their IRA funds do they need to fund their own retirement?
*
$ Total Household Real Estate Assets (gross value)
$ Total Outstanding Debt on Real Estate Assets (mortgage balance)
*
$ Business Valuation (if IRA owner owns a business)
% Percentage of Business Ownership (if IRA owner owns a business)
Type of Business(if IRA owner owns a business)
$ Total Household Net Worth
*
IRA owner's Current Marital Status
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Legally Married
Legally Divorced
Never Legally Married
If currently married, how many years?
If currently divorced, how many years since legally divorced?
Ages of Children (if IRA owner has children)
Spouse's Name (if IRA owner is currently married)
First
Last
Spouse's DOB (if IRA owner is currently married)
Date
Time
Spouse's Age (closest) or Date of Birth (if IRA owner is currently married)
Spouse's Projected Health Rating (if IRA owner is currently married)
Non-Smoker Best of Class
Non-Smoker Preferred
Non-Smoker Standard
Non-Smoker Table Rated
Smoker Preferred
Smoker Standard
Is Spouse a US Citizen? (if IRA owner is currently married)
Yes
No
Rating Rating owner
Spouse's Biological Gender At Birth (if IRA owner is currently married)
Male
Female
$ Spouse's Annual Income (if IRA owner is currently married)
List any questions or concerns that will help your back-office
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