Roth Conversion Planning Questionnaire - The Retirement Contractor

Roth Conversion Intake Form

1Your Details

2Assets - Part One

3Assets - Part Two

4Income & Expenses

5Tax & Roth Conversion

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This field is for validation purposes and should be left unchanged.

To help us prepare for your Roth conversion and retirement conversation, please provide the information you have available. Estimates are acceptable at this stage.

Do not enter account numbers, Social Security numbers, passwords or login details.

Primary Personal Information

Full name(Required)

Email(Required)

Phone(Required)

State(Required)

Current age(Required)

Desired retirement age

Current annual income

An approximate amount is acceptable.

Marital status(Required)

Single

Married

Divorced

Widowed

Domestic partnership

Employment status(Required)

Spouse or Partner Personal Information

Complete this section when your spouse or partner will be included in the retirement review.

Spouse or partner full name

Spouse or partner email

Spouse or partner phone

Spouse or partner current age

Spouse or partner desired retirement age

Spouse or partner current annual income

Spouse or partner employment status

Retirement Assets - Part One

Enter approximate totals. If you have more than one account of the same type, combine the values and use the notes field to provide a breakdown. Do not enter account numbers.

Savings, money market accounts and CDs - approximate current value

Savings, money market accounts and CDs - annual pre-retirement contribution

Brokerage accounts - approximate current value

Brokerage accounts - approximate cost basis

Brokerage accounts - annual pre-retirement contribution

Traditional or tax-deferred IRA - approximate current value

Traditional or tax-deferred IRA - annual pre-retirement contribution

Roth IRA - approximate current value

Roth IRA - annual pre-retirement contribution

SIMPLE IRA - approximate current value

SIMPLE IRA - annual pre-retirement contribution

Inherited IRA - approximate current value

Inherited IRA - annual pre-retirement contribution

Rollover IRA - approximate current value

Rollover IRA - annual pre-retirement contribution

SEP IRA - approximate current value

SEP IRA - annual pre-retirement contribution

401(k) - approximate current value

401(k) - annual pre-retirement contribution

Roth 401(k) - approximate current value

Roth 401(k) - annual pre-retirement contribution

Retirement assets - part one notes

Use this space to list multiple accounts or clarify any of the amounts above.

Retirement Assets - Part Two

Continue entering approximate totals. Do not enter account numbers.

SIMPLE 401(k) - approximate current value

SIMPLE 401(k) - annual pre-retirement contribution

Inherited Roth IRA - approximate current value

Inherited Roth IRA - annual pre-retirement contribution

Roth 403(b) - approximate current value

Roth 403(b) - annual pre-retirement contribution

403(b)/TSA - approximate current value

403(b)/TSA - annual pre-retirement contribution

Roth 457(b) - approximate current value

Roth 457(b) - annual pre-retirement contribution

401(a) - approximate current value

401(a) - annual pre-retirement contribution

Roth Thrift Savings Plan - approximate current value

Roth Thrift Savings Plan - annual pre-retirement contribution

Nondeductible IRA - approximate current value

Nondeductible IRA - annual pre-retirement contribution

Other qualified retirement account - approximate current value

Other qualified retirement account - annual pre-retirement contribution

Other tax-free account or asset - approximate current value

Other tax-free account or asset - annual pre-retirement contribution

Annuities, including fixed, variable and indexed annuities - approximate current value

Retirement assets - part two notes

Use this space to list multiple accounts, annuity types or any other relevant details.

Retirement Income

Primary annual Social Security benefit

Primary Social Security starting age

Spouse annual Social Security benefit

Spouse Social Security starting age

Primary annual pension

Spouse annual pension

Expected earned income in retirement

Other tax-free annual income

Other taxable annual income

Annual annuity income

Do you have a cash-value life insurance policy?(Required)

Yes

Unsure

Approximate current cash value

Annual premium being paid

Expenses

Estimated annual expenses

Include your usual household and lifestyle spending.

Additional or one-off expenses to include in the plan

Examples include travel, home renovations, vehicle replacement, family support or activities with grandchildren.

Tax

Tax filing status(Required)

Medicare and IRMAA

IRMAA is an income-related adjustment that may be added to Medicare Part B and Part D premiums. Thresholds and premiums can change.

What best describes your Medicare position?(Required)

I plan to begin Medicare at age 65

I have already started Medicare

I expect to delay Medicare

I am unsure

Not applicable yet

Estimated modified adjusted gross income at age 63 or from two years ago

An approximate amount is acceptable.

Estimated modified adjusted gross income at age 64 or from last year

An approximate amount is acceptable.

Additional Medicare or IRMAA information

Roth Conversions

Approximate Roth conversion amount being considered

Number of years over which the conversion is being considered

Has another adviser prepared Roth conversion scenarios for you?(Required)

Yes

Unsure

Please summarise the adviser recommendation

Do not upload or enter documents containing account numbers or other highly sensitive information.

Primary goal of the Roth conversion(Required)

Potential future tax flexibility

Reduce tax-deferred balances

Retirement-income planning

Estate or legacy planning

Required minimum distribution planning

Other

I am not sure yet

Heirs and legacy information

If the goal is to pass wealth to heirs, provide approximate ages, general employment and income information, marital status and any relevant legacy goals. Full names are not required.

Additional Roth conversion goals or questions

Other

Pre-retirement rate-of-return assumption

Enter a percentage, for example 6. Planning assumptions are not guaranteed rates of return.

Post-retirement rate-of-return assumption

Enter a percentage, for example 4. Planning assumptions are not guaranteed rates of return.

Other matters you would like to discuss

Acknowledgements

Privacy consent(Required)

I consent to The Retirement Contractor collecting and using this information to respond to my enquiry and prepare for our retirement conversation in accordance with the Privacy Policy.

Please review the current Privacy Policy before submitting.

Educational information acknowledgement(Required)

I understand that this intake form is used to prepare for an educational retirement-planning conversation and does not itself provide financial, investment, tax, legal, insurance or Medicare advice.

Document security: Please do not email account statements or documents containing account numbers, Social Security numbers, passwords or login information. If supporting documents are required, our team will provide secure submission instructions.

Roth Conversion Intake Form

Primary Personal Information

Spouse or Partner Personal Information

Retirement Assets - Part One

Retirement Assets - Part Two

Retirement Income

Expenses

Tax

Medicare and IRMAA

Roth Conversions

Other

Acknowledgements

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