Social Security Questionnaire

Married couples should fill out a single questionnaire, agreeing on their responses.

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1. Personal/Contact Information:

Your Name (required):
Date of Birth: (YYYY-MM-DD if typing.)
Telephone:
Your Email (required):
Spouse Name:
Spouse Date of Birth: (YYYY-MM-DD if typing.)

2. Are you still working?
You: YesNo
Spouse: YesNo

3. Expected "stop working" date:
You: (YYYY-MM-DD if typing.)
Spouse: (YYYY-MM-DD if typing.)

To calculate your Primary Insurance Amount independently, or to determine the possible impact of the Social Security Earnings Test, I need to know the earnings you expect for all future years, starting with the last year not shown in your Earnings Record on page 3 of the statement. For example, if the last year of earnings shown on your statement is 2013, please fill in your actual Social Security earnings for 2014 and your expected annual earnings from 2015 until your projected “stop working” date. By “stop working date” I mean the date after which you do not anticipate working full time or earning more than $15,720 in any year. By “earnings” I mean income received from employment that is subject to Social Security taxes.

Expected Social Security earnings each year until "stop working" date:

You:
2015
2016
2017
2018
2019
More years

Spouse:
2015
2016
2017
2018
2019
More years

4. Date of this Marriage: (YYYY-MM-DD if typing.)

5. Is your marital status likely to change in the foreseeable future? If yes, please explain:

People’s lives change constantly. For example, it would be very important for me to know if you are in the process of getting divorced; or if you are contemplating marriage; or if you or your spouse is faced with a life-threatening health situation.

6. Are you a United States citizen?
You: YesNo
Spouse: YesNo

7. Former marriages
This section should only be answered if:

  • You are (1) currently unmarried and (2) were previously divorced after a marriage that lasted at least 10 years (date of marriage to date divorce became final), or
  • You are (1) currently unmarried and (2) were widowed; or
  • You are (1) currently married, (2) were widowed, and (3) your remarriage occurred after you reached age 60.

You: Date of former marriage: (YYYY-MM-DD if typing.)
Date marriage ended (YYYY-MM-DD if typing.)
Reason marriage ended: DeathDivorce
Former spouse is AliveDead

Spouse: Date of former marriage: (YYYY-MM-DD if typing.)
Date marriage ended (YYYY-MM-DD if typing.)
Reason marriage ended: DeathDivorce
Former spouse is AliveDead

8. Do you have any minor or adult dependents at home?
Name:
Date of Birth: (YYYY-MM-DD if typing.)
If dependent is a minor, date of H.S. Graduation (YYYY-MM-DD if typing.)

Name:
Date of Birth: (YYYY-MM-DD if typing.)
If dependent is a minor, date of H.S. Graduation (YYYY-MM-DD if typing.)

9. Are you or your spouse currently receiving Social Security benefits?

You: YesNo
Spouse: YesNo

If yes please fill in next three blanks. This information is critical and must be accurate!

Type of benefits: DisabilitySpousalSurvivorRetirement

Current Monthly Benefits:

Date benefits began: (YYYY-MM-DD if typing.)

By “type of benefits” I mean retirement, spousal, disability, or survivor benefits. Please indicate the gross benefits, i.e., before deductions for Medicare premiums or withholding. Benefits are paid in arrears, and thus generally “began” the month before you received your first payment.

10. Do you expect to receive a pension based on non-Social Security covered employment?

Some (but not all) governmental, not-for-profit, or educational employers have opted out of the Social Security system. Such an employer may have paid you wages that were not subject to Social Security taxes. If you receive, or expect to receive, a pension based on employment that was not subject to Social Security taxes, please describe here.

You: YesNo
Spouse YesNo

Name of employer:
Number of years worked
Amount of pension per year
Cost of living adjustment in %
Date pension payments begin/began (YYYY-MM-DD if typing.)

11. Please rank order the following items 1 through 4 in order of their importance to you, where 1 is most important and 4 is least important. Even if one or more items seem of equal importance, please select a different number for each item. If one or more items are of no interest to you at all, please rank it 0.

Maximize the total combined benefits you would receive from the Social Security system if you each live to the life expectancies we are assuming pursuant to question #13

Maximize the combined monthly benefits you will receive at older ages (70’s, 80’s, 90’s)

Maximize benefits that the survivor of you will receive after one of you passes away

Maximize early benefits: start early and receive as much as possible while you are young

Other (please specify):

12. The report will illustrate a range of options available to you. However, if you have a strategy in mind that you would like to see illustrated, please describe it here.

You:
Spouse:

13. Normally I use the following life expectancy assumptions: Husband – 90 Wife – 95. The idea is not to predict how long you will live, but to think about how long one or both of you might live and the extent you might want to protect against the risk of running out of money if even one of you lives a long life. If you want me to use different assumptions, please provide those here:

Husband
Wife

For an average male/female couple each of whom is currently age 65, actuarial tables say there is a 36% probability of at least one spouse living for 30 more years , i.e., to age 95.

14. Do you or your spouse make contributions to a Health Savings Account (HSA)?

Husband: YesNo

Wife YesNo

If yes are you enrolled in Medicare?

Husband: YesNo

Wife YesNo

15. Please upload PDF copies of the current year Social Security statements for you and your spouse.

You:

Spouse:

Need help with this questionnaire? Call Peter at 802-229-0940

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