Complete our Secure Information Form Date MM slash DD slash YYYY Client Family Name(Required)Email(Required) Phone #(Required)Address Address City State / Province / Region ZIP / Postal Code Demographic InfoNameClientNameSpouse / Ex-Spouse*Birthdate MM slash DD slash YYYY ClientBirthdate MM slash DD slash YYYY Spouse / Ex-Spouse*Projected Maximum Age of LifeSee www.livingto100.com ClientProjected Maximum Age of LifeSee www.livingto100.com Spouse / Ex-Spouse*Relationship StatusInclude all marriages, divorces*, and deaths. Date of marriage(s), Date of divorce(s), Date of death(s) If more space is needed, enter in Additional Information below.ClientInclude all marriages, divorces*, and deaths. Date of marriage(s), Date of divorce(s), Date of death(s) If more space is needed, enter in Additional Information below.Spouse (Ex-Spouse*)Work & Claiming StatusAre you currently collecting benefits? Yes No ClientAre you currently collecting benefits? Yes No Spouse (Ex-Spouse*)If yes, start date and monthly amount?ClientIf yes, start date and monthly amount?Spouse (Ex-Spouse*)If yes, whose earnings record is the benefit based on? Own record Spouse’s record ClientIf yes, whose earnings record is the benefit based on? Own record Spouse’s record Spouse (Ex-Spouse*)If no, when do you plan to file for benefitsClientIf no, when do you plan to file for benefitsSpouse (Ex-Spouse*)Other claiming ages to reviewClientOther claiming ages to reviewSpouse (Ex-Spouse*)Last age (year) of earningsClientLast age (year) of earningsSpouse (Ex-Spouse*)Current year annual earningsClientCurrent year annual earningsSpouse (Ex-Spouse*)Dependent(s)Do you have any eligible children**? If yes, list all names and birth dates below Yes No ClientDo you have any eligible children**? If yes, list all names and birth dates below Yes No Spouse (Ex-Spouse*)Upload the Social Security Earnings Record XML File Drop files here or Select files Max. file size: 100 MB. Download your Social Security XML File at My Social Security Additional Information*Ex-spouse benefits may be available if married at least 10 years, are currently unmarried, and at least 62 years old. **Children’s benefits may be available if children are under age 19, still in high school, or were permanently disabled before age 22.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
