Retirement Worksheet

Please fill out the form below to the full extent of your abilities. The more information we obtain from you, the more we will be able to help going forward!

Full Name

Preferred Contact Method


Desired Retirement Age

Years Until Retirement

Life Expectancy

Social Security Income at Retirement

Expected Rate of Inflation

Desired percentage of pre-retirement income (replacement income) 

Desired dollar amount of monthly retirement income 

Do you have specific plans to assure this desired retirement income? 

Do you want to rely on Social Security? 

Do you expect your taxes to be higher now or in retirement?

Do you have a good mix of qualified, non-qualified, and tax-free retirement funds? 

Please describe your ideal retirement: 




1840 5th St. Springfield, OR 97477  |  (O) 541-583-0093  |

Investment advice is offered through Belpointe Asset Management, LLC. Insurance and annuity products may be offered through D.H. Hill Securities, LLLP. Securities are offered through D.H. Hill Securities, LLLP, Member FINRA/SIPC. D.H. Hill Securities, LLLP, Todd Mann Financial Services Inc., and Belpointe Asset Management, LLC are not affiliated entities. Todd Mann Financial Services Inc. is currently insurance licensed in the states of Oregon, New Jersey, and Wisconsin.

Insurance and annuity products may be offered through D.H. Hill Securities, LLLP. 


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