FFM - 403(b) - Request Form

403(b) General Request Form

Please complete the following confidential request form to receive FREE information on 403(b) investing. Please note: All fields must be completed.

  Name:         
  Address:    
  City:         State/Province: 
  Zip Code:   
  Email:      
  Home Phone:   
  Work Phone: 

  Occupation: 
  Employer:   
  
  Do you own a 403(b) now?          
     Yes   No
  
  Are you looking for a possible "rollover" or transfer of your 403(b) plan?   
     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:
     28%    31%    36%    39.6%    Unknown
  
  Your estimated time frame to establish a 403(b) plan is?
     Less than one month    1 to 3 months    3 to 6 months

  Your general awareness on this subject is:

  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):

  Additional Comments/Questions:

Securities are offered through Girard Securities, Inc. member FINRA, SIPC.
Mark R. Fielder, Registered Principal. CA. Insurance Lic. # 0690576.

Disclosure: Variable Annuities are long-term investments designed for retirement purposes and are subject to market fluctuations, investment risks and possible loss of principal. For more complete information about variable annuities, including charges and expenses, obtain a prospectus by calling 1-800-480-7526. Read it carefully before you invest or send money. Withdrawals may be subject to income tax and a 10% IRS imposed penalty may apply on withdrawals made prior to age 59-1/2. Consult your tax advisor.