Nationwide Social Security Fact Finder

Social Security 360 Analyzer® Fact Finder

Wholesaler name:*
Meeting reference:*
REPORT REQUESTED BY:
- BROKER/DEALER
- BGA
- IMO
- RIA
Name:*
First Name: Last Nane:
Firm/BGA/IMO Name:*
Phone:*
Send Report To (Email):*
Address (Street, City, State, Zip Code):*
About you
Answer the questions below and bring this form to a Social Security planning meeting with your advisor. (If you select married, widowed or divorced, be sure to answer the related questions on Page 2 in addition to the questions below.)
Name:*
First Last
Your marital status:*
- Married
- Widowed
- Divorced
- Single
Gender:*
- Male
- Female
Date of birth:*
Month
Day
Year
What life expectancy are you planning for?
months
- Use average (Male= 86 years, Female=89 years)*
Have you already started Social Security benefits?*
- Yes
- No
If yes, at what age
Filing date:*
Month
Day
Year
If so, how much is the monthly benefit you’re currently receiving?
Government or Non-profit Employees/Former Employees
Do you have a pension from employment in which you did NOT pay Social Security taxes?*
- Yes
- No
If yes, Page 3 of your SS benefit statement “Your earnings statement” is required with this questionnaire to generate a report.
What is the name of the pension/employer?
What is the monthly pension amount?
When does this pension start?
What is the projected cost-of-living adjustment for this pension?
Your earnings
For this section, please refer to a current Social Security benefit statement.
Statement date:
Month
Day
Year
Your estimated monthly benefits at full retirement age:
At what age do you plan to stop working?
If you’re planning to work after 62, what is your anticipated annual employment income?
Your retirement income assumption
What is your desired monthly pre-tax household income upon retirement?
What is your desired monthly pre-tax household income after the death of your spouse?
¹ Life expectancy for a married couple at age 65, 2015 LIMRA Retirement Income Reference Book
About your spouse
Name:
First Last
Gender:
- Male
- Female
Date of birth:
Month
Day
Year
What life expectancy are you planning for?
months
- Use average (Male= 86 years, Female=89 years)*
Have you already started Social Security benefits?
- Yes
- No
If yes, at what age
Filing date:
Month
Day
Year
If so, how much is the monthly benefit you’re currently receiving?
Government or Non-profit Employees/Former Employees
Do you have a pension from employment in which you did NOT pay Social Security taxes?
- Yes
- No
If yes, Page 3 of your SS benefit statement “Your earnings statement” is required with this questionnaire to generate a report.
What is the name of the pension/employer?
What is the monthly pension amount?
When does this pension start?
What is the projected cost-of-living adjustment for this pension?
Your spouse earnings
For this section, please refer to a current Social Security benefit statement.
Statement date:
Month
Day
Year
Your estimated monthly benefits at full retirement age:
At what age do you plan to stop working?
If you’re planning to work after 62, what is your anticipated annual employment income?
If you’re widowed
If eligible for survivor benefits you will need proof of marriage and death to retrieve benefits for a deceased spouse when you visit your local SSA office.
Deceased spouse’s date of birth (mm/dd/yy):
Month
Day
Year
How long were you married?
months
What monthly benefit amount would you receive if you elect widow’s benefits at your full retirement age?
What is the monthly primary insurance amount (PIA) of your deceased spouse?
If you’re divorced
You may be eligible for benefits based on an ex-spouse’s record, if you were married for at least 10 years. You will need proof of marriage and divorce to retrieve information and benefits for an ex-spouse when you visit your local SSA office.
Ex-spouse’s date of birth (mm/dd/yy):
Month
Day
Year
What is your ex-spouse’s anticipated life expectancy?
months
- Deceased
How long were you married?
months
At what age does your ex-spouse plan to claim benefits?
months
What monthly benefit amount would you receive if you elect spousal benefits at your full retirement age (or soonest available if you are more than 6 years older than your ex-spouse)?
• Not a deposit • Not FDIC or NCUSIF insured • Not guaranteed by the institution • Not insured by any federal government agency • May lose value The information collected on this questionnaire will be kept confidential and used to provide an estimate of your Social Security benefits in retirement. For more information on how Nationwide protects your personal information, visit our online privacy policy at www.nationwide.com/privacy-security.jsp. Keep in mind that any estimate resulting from this fact finder is for hypothetical purposes only and is not a guarantee. This material is not a recommendation to buy, sell, hold or roll over any asset, adopt an investment strategy, retain a specific investment manager or use a particular account type. It does not take into account the specific investment objectives, tax and financial condition, or particular needs of any specific person. Investors should work with their financial professional to discuss their specific situation. This is being provided for informational purposes only and should not be construed as investment, tax, or legal advice. The information provided is based on current laws, which are subject to change at any time, and has not been endorsed by any government agency. Nationwide Investment Services Corporation (NISC), member FINRA, Columbus, OH. Nationwide Retirement Institute is a division of NISC. Social Security 360 Analyzer is a service mark of Nationwide Life Insurance Company. Nationwide and the Nationwide N and Eagle are service marks of Nationwide Mutual Insurance Company. © 2019 Nationwide NFM-11991AO.9 (01/19)

About you

Government or Non-profit Employees/Former Employees

Your earnings

Your retirement income assumption

About your spouse

Government or Non-profit Employees/Former Employees

Your spouse earnings

If you’re widowed

If you’re divorced