Social Security – Online Form – English

    Social Security Questionnaire

    Use a Single Questionnaire for Married Couples

    1. Personal Information (* indicates a required field)

    2. Are you Married?

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

    YOU:

    When benefits began:
    Current Monthly Benefits ($):
    SPOUSE:

    When benefits began:
    Current Monthly Benefits ($):

    4. Past Earnings

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

  • Upload earnings record from the Social Security website into a .pdf file
  • Use Estimated Gross Monthly Retirement at Full Retirement Age (FRA)
  • YOU:
    I will copy earning data from the Social Security Website:
    If Yes, see INSTRUCTIONS below.
    I will use Estimated Gross Monthly Retirement at FRA:
    If Yes, enter Estimated Gross Monthly Retirement at FRA ($):
    SPOUSE:
    I will copy earning data from the Social Security Website:
    If Yes, see INSTRUCTIONS below.
    I will use Estimated Gross Monthly Retirement at FRA:
    If Yes, enter Estimated Gross Monthly Retirement at FRA ($):


    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:

  • Former marriages
  • Minor or Adult dependents living at home
  • A job where you did NOT pay Social Security taxes and expect to receive a pension
    based on this job, etc.

  • 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:
    SPOUSE:


    How to Proceed:

  • Fill the questionnaire and SUBMIT it.
  • Upload the PDF copies of the past earnings for you and your spouse (see Instructions to "Past Earnings").
  • Send the uploaded copies of the past earnings to: info@libertymedicare.com

  • For any help with this questionnaire, call Liberty Medicare at 877.657.747