Retirement Questionnaire - Hilliard Lyons

Retirement Questionnaire
Securities offered through J.J.B. Hilliard, W.L. Lyons, LLC | Member NYSE, FINRA & SIPC.
Hilliard Lyons does not offer tax or legal advice. Contact your tax or legal advisor about your specific situation.
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Retirement Questionnaire
Financial Consultant Branch
PERSONAL INFORMATION
First Name Middle Last ____________________________________
Birthdate (mm/dd/yyyy) Gender Male Female SSN ________________________________
Address__________________________________________________________________________________________________
________________________________________________________________________________________________________
City State Zip ______________________________
CO-CLIENT INFORMATION
First Name Middle Last ____________________________________
Birthdate (mm/dd/yyyy) Gender Male Female SSN ________________________________
DEFINE YOUR RETIREMENT GOAL
CLIENT CO-CLIENT
What is your current annual earned income?
What earned income growth rate do you expect on your
current income?
At what age do you plan to retire?
At what age do you expect your retirement to end? (Default age 90)
$ $
PRE-RETIREMENT POST-RETIREMENT
What average income tax rate* (state & federal) do you want to
assume?
*Figure this rate by dividing the total dollar amount of income taxes you
paid last year (state, federal and local as applicable) by your income.
What amount would you like to spend annually during retirement
(after-tax)?
$
Debt Obligations
DESCRIPTION INTEREST RATE CURRENT BALANCE MONTHLY PAYMENT AMOUNT
% $ $
% $ $
% $ $
% $ $
Hilliard Lyons does not offer tax or legal advice. Please consult your tax advisor or attorney before making any decision that may affect your tax or legal situation.
Securities offered by J.J.B. Hilliard, W.L. Lyons, LLC | Member NYSE, FINRA & SIPC. ©2011 All rights reserved.

EXPENSES
Use the table below to anticipate what your monthly primary and discretionary retirement expenses may be. Keep in mind that some of
your expenses - auto fuel for instance - may be lower once you’re retired. Other expenses - such as your utilities - may increase.
Expense Items Primary Expenses Discretionary Expenses
Housing Mortgage or Rent $ $
Taxes and Insurance $ $
Utilities $ $
Maintenance $ $
Phone $ $
Household Supplies $ $
Security System $ $
Furnishings/Home Decor $ $
Food Groceries $ $
Dining $ $
Auto Expenses Loan or Lease Payments $ $
Taxes and Insurance $ $
Maintenance $ $
Fuel $ $
Healthcare Health Insurance $ $
Medicare $ $
Co-pays $ $
Medicine $ $
Other (supplies, gym membership) $ $
Insurance Life Insurance $ $
Long-term care insurance $ $
Personal Clothing $ $
Care Products $ $
Dry Cleaning $ $
Glasses/Contacts $ $
Recreation Hobbies $ $
Entertainment $ $
Travel $ $
Cable/Internet $ $
Gifts Holidays, Anniversaries, Birthdays $ $
Charitable Donations $ $
Taxes Income Tax $ $
Other Taxes $ $
Other $ $
$ $
TOTAL MONTHLY EXPENSES $ $

RETIREMENT ASSETS
(provide the requested information about your retirement assets (401k, IRA, Roth IRA, Profit Sharing, etc.)
QUALIFIED RETIREMENT ASSETS
(401K, IRA, OTHER)
Description
Owner
ASSET 1 ASSET 2 ASSET 3 ASSET 4
Client
Co-Client
Client
Co-Client
Client
Co-Client
Current Balance $ $ $ $
Annual Contribution (Employee) $ $ $ $
Annual Contribution (Employer)
Annual Rate of Return
$ $ $ $
Client
Co-Client
OTHER ASSETS (provide the requested information about other assets you own that would be available for retirement.)
CASH ASSETS
Description
ASSET 1 ASSET 2 ASSET 3 ASSET 4
Current Balance $ $ $ $
Percent available for retirement % % % %
Annual Contribution
INVESTMENT ASSETS
Description
$ $ $ $
Current Balance $ $ $ $
Cost Basis $ $ $ $
Percent available for retirement % % % %
Annual Contribution $ $ $ $
Rate of Return
BUSINESS/REAL ESTATE/RENTAL/PERSONAL ASSETS
Description
% % % %
Current Value $ $ $ $
Cost Basis $ $ $ $
Percent available for retirement % % % %
Rate of Return % % % %
Hilliard Lyons does not offer tax or legal advice. Please consult your tax advisor or attorney before making any decision that may affect your tax or legal situation.
Securities offered by J.J.B. Hilliard, W.L. Lyons, LLC | Member NYSE, FINRA & SIPC. ©2011 All rights reserved.

INCOME SOURCES (Social Security, Pension, and Other Income Sources)
CLIENT CO-CLIENT
Are you covered by Social Security? Yes No Yes No
At what age do you want your benefits to begin?
What do you expect your annual Social Security benefit
amount to be?
What do you expect your
annual pension amount to be?
$ $
PENSION- CLIENT PENSION - CO-CLIENT
$
Start Age Start Age
What do you expect your
annual pension amount to be?
Survivor Benefit % Survivor Benefit %
OTHER INCOME DURING RETIREMENT SOURCE 1 SOURCE 2 SOURCE 3
Description
Annual Income $ $ $
Years until income begins
Years income continues
Rate income increases annually % % %
Percent Taxable % % %
NOTES/GOALS
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$