Rollover/Transfer General Request Form

Please complete the following request form to receive FREE information on Rollover and Transfer options. Please note: All fields must be completed.

  Name:            
  Address:       
  City:          
  State:         
  Zip Code:      
  Email:         
  Confirm Email: 
  Home Phone:      
  Cell Phone:    

  What type of plan are you looking to rollover or transfer?
    

  Will you be making future contributions?
     Yes   No
  
  I consider myself a:
     Aggressive Investor    Moderate Investor   
     Conservative           Willing to accept NO risk  
    
  Are you a mutual fund investor?
     Yes   No
    
  Your age is:
     25-35    35-45    45-55    55-65   65-Above
    
  Your tax bracket is:
     10-15%    25-28%    33-35%    Unknown
  
  Approximate rollover/transfer amount: 
  
  Your estimated time frame to establish such a plan is?
     Less than one month    1 to 3 months    3 to 6 months
  Your general awareness on this subject is:
     
  
  Additional Comments/Questions:
  

   

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All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.