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 __________________________________________________________________ |
-----------------------
Spouse?
Yes No
Children?
Yes No
................
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