Federal Benefits Analysis Client Questionnaire
  1. Employee Name:(*)
    Missing full name
  2. Address:(*)
    Missing street address
  3. City(*)
    Missing city name
  4. State:(*)
    Missing State name
  5. Zip Code:(*)
    Missing Zip Code information
  6. Home Phone:
    Invalid Input
  7. E-mail Address:
    Invalid Input
  8. Employee\'s Birth Date:(*)
    Missing Date of Birth
    (mm/dd/yyyy)
  9. Spouses\' Birth Date:
    (mm/dd/yyyy)
  10. Employee\'s Service Computation Date (SCD):
    Invalid Input
    (to include military time)
  11. Have you made contributions to your retirement system since your SCD to retirement?
    Invalid Input

  12. Have you ever taken Leave Without Pay?
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)
  13. Were you ever on worker's compensation
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)
  14. Do you have any part time work before 4/7/86?
    Invalid Input

  15. Do you have any part time work after 4/7/86?
    Invalid Input

  16. Average hours of any part time work
    Invalid Input
  17. Average salary of any part time work
    Invalid Input
  18. Did you ever have intermittent (WAE) work?
    Invalid Input
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)
  19. Did you ever have a break in service?
    Invalid Input
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)
  20. If you retired from the military, does your retirement include Combat Disability or the Reserves?
    Invalid Input

  21. What were your dates of service?
    Invalid Input
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)
  22. Do you plan to waive your military retirement pay in order to include with your civilian service?
    Invalid Input

  23. Have you made a deposit for your military service?
    Invalid Input

  24. Do you have any non-deduction (temporary time) service?
    Invalid Input
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)
  25. Did you ever have a break in service and withdraw your contributions to your retirement system?
    Invalid Input
    Please enter dates (dd/mm/yyyy to dd/mm/yyyy)

  26. Employee's Desired Retirement Date:
    Invalid Input
  27. Retirement System:
    Invalid Input
  28. If Transfer, Transfer Date:
    Invalid Input
    (dd/mm/yyyy)
  29. Employee Type:
    Invalid Input
  30. Retirement Type:
    Invalid Input
  31. Survivor Benefit Desired:
    Invalid Input
    Enter percentage for CSRS and FERS
  32. CSRS Sick Leave Hours to be Saved Each Pay Period:
    Invalid Input
    (Hours - biweekly)
  33. CSRS Sick Leave Saved To Date:
    Invalid Input
    (Hours)
  34. Employee's Expected Annual Salary Increase (%) Each Year:
    Invalid Input
    (enter percent increase)
  35. Employee's Current Annual Salary:
    Invalid Input
    (Include locality pay for GS in the 48 continuous states, night differential and environmental pay for wage grade. AUO and LEAP for Law Enforcement.. Physicians and Dentists under Title 38 at the VA, special pay)
  36. Monthly Social Security Benefit at Age 62:
    Invalid Input
    (FERS, Transfer, CSRS Offset)
  37. Monthly Social Security Benefit at Age 62 Attributable to Offset:
    Invalid Input
    (CSRS Offset)
  38. Annual Social Security COLA
    Invalid Input
    (FERS, Transfer, CSRS Offset)

  39. Federal Employees Group Life Insurance Coverage

    Basic:
    Invalid Input
  40. If Yes, Reduction at age 65:
    Invalid Input
  41. Option A:
    Invalid Input
  42. Option B:
    Invalid Input
  43. If Yes, How Much?
    Invalid Input
    (times)
  44. Reduce After Age 65?
    Invalid Input
  45. Spouse Covered:
    Invalid Input
  46. If yes, How Much?
    Invalid Input
    (times)
  47. Coverage Reduce After Age 65?
    Invalid Input
  48. Dependents Covered:
    Invalid Input
  49. Coverage Eligible after Age 22:
    Invalid Input

  50. Thrift Savings Plan – Savings and Withdrawal

    Current Savings in Funds:
    Invalid Input

  51. Investing:

    Percent of Salary to invest each year:

    2009:
    Invalid Input
    %
  52. 2010:
    Invalid Input
    %
  53. 2011:
    Invalid Input
    %
  54. 2012:
    Invalid Input
    %

  55. Catch-up Contribution (eligible starting in year age 50 is reached):

    2009:
    Invalid Input
    ($0 to $2,000)
  56. 2010:
    Invalid Input
    ($0 to $3,000)
  57. 2011:
    Invalid Input
    ($0 to $4,000)
  58. 2012:
    Invalid Input
    ($0 to $5,000)
  59. Percent Invested in Each Fund:
    Invalid Input
    (Amounts entered must total 100%)
  60. Expected Rates of Return for each fund:
    Invalid Input
  61. Withdrawal:
    Invalid Input
  62. If Monthly Amount, then Realign $ into Fund:
    Invalid Input
  63. Withdrawal (to start):
    Invalid Input
    (dd/mm/yyyy)

  64. Long Term Health Care

    Name of Person to be Insured:
    Invalid Input
  65. Age:
    Invalid Input
  66. Daily Benefit Amount:
    Invalid Input
    ($50 to $300 in $25 increments (e.g., $50, $75, $100, etc.)
  67. Benefit Period:
    Invalid Input
  68. Waiting Period:
    Invalid Input
  69. Inflation Protection:
    Invalid Input
  70. Submit Form