Roth IRA Conversion Form - Imagisoft



Roth IRA Conversion Form

|1. Client Information |

|First |Middle |Last |

|Gender |Age |Date of Birth (M/D/Y) |Assumed Age at Death |

|Address |

|City |State |Zip Code |

|Phone |Email |

|2. Spouse Information |

|First |Middle |Last |

|Gender |Age |Date of Birth (M/D/Y) |Assumed Age at Death |

|3. Dependent Children |

|Name |Gender |Date of Birth (M/D/Y) |

|Name |Gender |Date of Birth (M/D/Y) |

|Name |Gender |Date of Birth (M/D/Y) |

|Name |Gender |Date of Birth (M/D/Y) |

|4. Client Income Information |

| |Amount ($) |Increase (%) |From (age) |To (age) |

|Defined Benefit Plans | | | | |

|Wages | | | | |

|Annuity | | | | |

|Other | | | | |

|5. Spouse Income Information |

| |Amount ($) |Increase (%) |From (age) |To (age) |

|Defined Benefit Plans | | | | |

|Wages | | | | |

|Annuity | | | | |

|Other | | | | |

Roth IRA Conversion Form cont.

|6. Tax Assumptions |

|Filing Status: |□ Single |Itemized Deductions |

| | |(excluding mortgage interest) |

| |□ Married Filing Jointly | |

| |□ Married Filing Separately | |Amount ($) |

| |□ Head of Household |

|7. Assumed Future Tax Law Changes |

|Tax Bracket Inflation Adjustment |Percent (%) |

|Tax Bracket Percentage Change |Percent (%) |Year |

|□ Proposed 28% Limit on Itemized Deductions |

|□ Proposed Health Care Surcharge |

|8. Asset Information |

| |

|9. Residence Information |

|Residence |Mortgage |Equity Line of Credit |

|Current Value ($) |Balance ($) |Current Value ($) |

|Appreciation Rate (%) |Interest Rate (%) |Appreciation Rate (%) |

|Purchase Price |Monthly Payment |Purchase Price |

| |

|10. Client Main Objective |

|□ Larger Estate for Posterity |□ Higher After-Tax Income for Spouse |□ Higher Personal After-Tax Income |

|□ Other __________________________________________________________________ |

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Spouse?

Yes No

Children?

Yes No

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