Social Security – Online Form – English

Social Security Questionnaire

Use a Single Questionnaire for Married Couples

First Name (*):

Last Name (*):

Date of Birth (*):

Phone Number (*):

Email (*):

Spouse First Name:

Spouse Last Name:

Spouse Date of Birth:

2. Are you Married?

YesNo

If Yes, Date of Marriage:

3. Are you or your spouse receiving any Social Security Benefits?

YOU:YesNo

If Yes, provide the information below:
Type of Benefits:
RetirementSpousalSurvivorDisability

When benefits began:

Current Monthly Benefits ($):

SPOUSE:YesNo

If Yes, provide the information below:
Type of Benefits:
RetirementSpousalSurvivorDisability

When benefits began:

Current Monthly Benefits ($):

4. Past Earnings

You have two options to submit your past earnings (EACH of YOU for married couples):

YOU:
I will copy earning data from the Social Security Website: YesNo

If Yes, see INSTRUCTIONS below.

I will use Estimated Gross Monthly Retirement at FRA: YesNo

If Yes, enter Estimated Gross Monthly Retirement at FRA ($):

SPOUSE:
I will copy earning data from the Social Security Website: YesNo

If Yes, see INSTRUCTIONS below.

I will use Estimated Gross Monthly Retirement at FRA: YesNo

If Yes, enter Estimated Gross Monthly Retirement at FRA ($):

INSTRUCTIONS: How to upload your earnings from the Social Security website
1. Go to the Social Security Administration website and create My Social Security account if you don't already have one
2. Login into My Social Security using user name and password
3. Click the "Earnings record" link
4. Click “Print / Save Your Full Statement”
5. Save the copy of your earnings as the .pdf file
6. Upload a PDF copy of the file

5. Future Earnings

If you copied earning data from Social Security Website, enter “Stop Working Date” here. “Stop
Working Date” is the date after which you DO NOT EXPECT your yearly income will modify the
list of the highest 35 years of yearnings.

YOU:
Stop Working Date:
SPOUSE:
Stop Working Date:

For each of the years starting with the last year (LY) NOT SHOWN in the Earning Record on
your Social Security Statement and UP to “Stop Working Date”, enter the expected yearnings ($):

YOU:

LY:

LY+1:

LY+2:

LY+3:

LY+4:

LY+5:

LY+6:

LY+7:

LY+8:

LY+9:

SPOUSE:

LY:

LY+1:

LY+2:

LY+3:

LY+4:

LY+5:

LY+6:

LY+7:

LY+8:

LY+9:

6. The questionnaire above does not include more complex situations, such as:

If you are in one of such situations, we’ll provide an additional set of questions.

7. The Specific “WHAT‐IF” Strategy

The PERSONALIZED DETAILED REPORT includes the maximized strategy and the default WHAT‐IF strategy. We also can generate the UNLIMITED number of WHAT‐IF strategies.

If you have a SPECIFIC WHAT‐IF strategy in mind that you'd like to run, please describe it below.

YOU:

SPOUSE:

8. Life Expectancy

We usually use a Life Expectancy calculator based on your Gender and Date of Birth. If you want us to use the specific numbers, please enter them:

Your Life Expectancy (yrs.):

Spouse Life Expectancy (yrs.):

9. Are you enrolled, or plan to enroll, in Medicare

YOU:YesNo

SPOUSE:YesNo