Social Security Optimization Questionnaire - Messina's Wealth Management

Section 1: Personal Information - Step 1 of 5

Please provide your contact information so we can personalize your Social Security strategy.

Name *

First

Last

Date of Birth *

Email *

Phone

Spouse / Partner Full Name (if applicable)

Tell us about your current Social Security and employment situation.

Have you STARTED receiving Social Security benefits? *

If YES, what month and year did you start?

Date

Time

Are you currently working? *

Approx. annual income from work or self-employment *

Have you ever worked in a job that did NOT pay into Social Security?

Yes
No
Unsure

Current Marital Status *

Married
Divorced
Widowed
Single/Never Married

If divorced or widowed, how long were you married?

Is your spouse or ex-spouse currently receiving Social Security? *

Yes
No
Not Sure
Not Applicable

Do you have any dependent children under 18 (or 19 if in school)? *

Help us understand your filing preferences. If you've checked SSA.gov, share your estimated amounts

What age are you planning to START Social Security? *

Age 62
Full Retirement Age (FRA)
Age 70
Not sure yet

What is MOST important when choosing when to file? *

Income ASAP
Maximize lifetime benefit
Protect spouse/survivor
Coordinate with other retirement income

Have you reviewed your Social Security statement on SSA.GOV in the last 12 months? *

Yes
No
I don't know how

Estimated monthly benefit at Age 62:

Estimated monthly benefit at Full Retirement Age (FRA):

Estimated monthly benefit at Age 70:

Spouse's estimated monthly benefit at Full Retirement Age (FRA):

Understanding your health, retirement timeline, and income sources helps us build a more accurate
strategy.

How would you describe your overall health? *

Excellent
Good
Fair
Poor

Does longevity run in your family? *

Yes
No
Unsure

Life expectancy assumption or family history:

Target Retirement Age:

Total estimate of retirement savings (401k, IRA, etc.):

Do you have a pension?

If yes, approximate monthly pension amount:

to focus Full

Which retirement income sources will you have? *

IRA/401(k)
Pension
Annuity
Investment Accounts
Rental/Real Estate
Social Security
Other

These optional questions help us address tax exposure, special provisions, and your planning priorities.

Do you expect income that could make Social Security taxable?

Yes
No
Not Sure

Subject to WEP or GPO?

Yes
No
Not Sure
I don't know what this is

Any prior marriages lasting 10+ years?

State of Residence:

Are you concerned about Medicare Part B IRMAA surcharges?

Yes
No
I don't know what this is

Annual Income Needs in Retirement:

What should we focus on in your Social Security strategy review? *

Would you like us to contact you? *

Yes, please contact me to schedule
Not right now

Social Security
Optimization Questionnaire

To help us create your personalized Social Security strategy, please take a few minutes to complete this brief questionnaire. Your responses will allow our team to better understand your situation and prepare meaningful insights ahead of your consultation.

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