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Savings Snapshot
How much are you currently saving?
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Savings Snapshot
Fill out the form below to receive more information.
the My New Retirement™ strategy
would work with your unique situation.
Fields marked with an asterisk(*) are required.
First Name:
Last Name:
Email address *
Phone
Date of Birth *
Gender *
FEMALE
MALE
Marital Status *
SINGLE
MARRIED
Number of Children under 18 *
0
1
2
3
4
5
6
7
8
9
10
Annual Income Range *
$ 0 - 49,999
$ 50,000 - 74,999
$ 75,000 - 99,999
$ 100,000 - 124,999
$ 125,000 - 149,999
$ 150,000 - 199,999
$ 200,000 +
Currently saving per month *
$ 0
$ 50
$ 100
$ 150
$ 200
$ 250
$ 300
$ 350
$ 400
$ 450
$ 500
$ 550
$ 600
$ 650
$ 700
$ 750
$ 800
$ 850
$ 900
$ 950
$ 1000
$ 1500
$ 2000
$ 2500
$ 3000
$ 4000
$ 5000+
How much more could you save? (monthly) *
$ 0
$ 50
$ 100
$ 150
$ 200
$ 250
$ 300
$ 350
$ 400
$ 450
$ 500
$ 550
$ 600
$ 650
$ 700
$ 750
$ 800
$ 850
$ 900
$ 950
$ 1000
$ 1500
$ 2000
$ 2500
$ 3000
$ 4000
$ 5000+
State of Residence *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New_Hampshire
New_Jersey
New_Mexico
New_York
North_Carolina
North_Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode_Island
South_Carolina
South_Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West_Virginia
Wisconsin
Wyoming
Current savings vehicles
401(k)/403(b)/457/etc.
Roth
IRA
CD
Stocks
Bonds
Mutual Funds
Annuities
Other
Do you feel you are saving enough for retirement? *
Yes
No
Are you concerned you may outlive your savings? *
Yes
No
Are you going to provide some or all of your child's college funding? *
Yes
No
Do you use products containing nicotine? *
Yes
No
Additional Information to Consider
Save Snapshot
Your retirement specialist:
Earl Rimple
earl@earlthemoneycoach.com
4074051070
