ROTH IRA General Request Form

Please complete the following request form to receive FREE information on ROTH IRA investing. Please note: All fields must be completed.

  Name:            
  Address:       
  City:          
  State:         
  Zip Code:      
  Email:         
  Confirm Email: 
  Home Phone:      
  Work Phone:      
  
  Are you looking to establish a new Roth IRA plan?
   Yes   No
  Do you own an Roth IRA now?          
   Yes   No
  
  Are you looking to transfer your Roth IRA plan?
   Yes   No
  
  I consider myself a:
   Aggressive Investor    Moderate Investor   
   Conservative Investor  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?
   15%    25%    28%    33%    35%
  
  Your estimated time frame to purchase or rollover a Roth plan?
   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:
  

   

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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.