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					Dollar amount?*   Choose Not sure $0 - $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $11,000 $12,000 $13,000 $14,000 $15,000 $16,000 $17,000 $18,000 $19,000 $20,000 $21,000 $22,000 $23,000 $24,000 $25,000 $26,000 $27,000 $28,000 $29,000 $30,000 $31,000 $32,000 $33,000 $34,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000 $600,000 $700,000 $800,000 $900,000 $1,000,000 Other amount Age* Choose 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Where is money now* Choose CD IRA 401 K Mutual Fund Savings Account Other Plan to add funds? Choose No plan on adding funds Monthly Quarterly Yearly If so, how much? Choose Not sure $0 - $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $11,000 $12,000 $13,000 $14,000 $15,000 $16,000 $17,000 $18,000 $19,000 $20,000 $21,000 $22,000 $23,000 $24,000 $25,000 $26,000 $27,000 $28,000 $29,000 $30,000 $31,000 $32,000 $33,000 $34,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 Other amount Receive payments when Choose Immediately 5 Years 10 Years 15 Years 20 Years 25 Years 25+Years     Contact's residence:   Name* Address City* State* Zip code*     Contact's info:   Email* {Check for email accuracy} Home phone* --  Please supply a valid phone. Work phone --  Ext Cell phone --     Best contact method* Choose Phone Email Phone & Email Best contact time Choose ASAP Anytime Morning Afternoon Evening 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12 Noon 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm 8:00 pm 9:00 pm Comments