Social Security Analysis Form

Full Name *

Address *

City *

State *

Zip *

Email *

Phone Number *

Birth Date *

Marital Status: *

If married, have you been married for at least 1 year? *

If divorced, did any prior marriage last longer than 10 years? *

Do you have any children? *

Are any children under the age of 18? *

Were any of your children disabled before their 22nd birthday? *

What were your “Social Security Wages” as shown on last year’s W-2? *

What are your estimated gross wages (before any deductions) for this year? *

Type of business *

If NOT incorporated what were your net earnings on Schedule C for last year

What are your estimated net earnings for this year

Retirement *

Medicare *

Widow/Widower benefit *

Disability *

If yes, please provide the gross benefit amount

Month and Year it started

Did you ever work at a job where Social Security taxes were not withheld? ie: federal, state, county, city governments, or a foreign country? *

If yes, please provide the monthly (actual or estimated) gross amount of this pension.

Do you have definite plans on when you will stop working or significantly cut back your earnings from job or self-employment? *

If Yes, what date do you plan to retire? (mm/dd/yyyy)

Who referred you to Social Security Solutions?

Please provide any additional remarks that you wish to include.

I have read and agree to all terms and conditions as outlined on the Agreement page *

I have or will get my Social Security Statement from Social Security and send it to Social Security Solutions, LLC for a retirement analysis. *