Qualcomm Retirement Planning Review Questionnaire

Personal Information

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(*) denotes a required field

First Name: *

Last Name: *

Address: *

City: *

State: *
CaliforniaAlabamaAlaskaAmerican SamoaArizonaArkansasColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zip Code: *

Cell Phone: *

Business Phone: *

Home Phone:

Email: *

Participant Birth Date:

Beneficiary Birth Date:

Select:
SpousalNon-Spousal

Spouse's Name (if applicable):

Estimated Date of Retirement or Separation from Service:

Retirement Information

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Amount of Distribution:
*Input all applicable fields you are eligible for (Parts A-D)

 
 
1) Part A:

Lump Sum ($)

Annuity ($)

 
 
2) Part B:

($)

 
 
/ Part C:

($)

 
 
2) Part D:

($)

Savings Plan 401(k) ($)

Contribution %

After-Tax Contribution Amount (if any) ($)

Total Rollover ($)

Age You Would Like Withdrawals to Begin

Employee Information

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Position:

Years With Company:

Annual Salary:

Outside Capital and Income

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Stock Portfolio Value:

Notes:

Liquid Investments:

Notes:

Current IRA Accounts:

Notes:

Tax Free Investments:

Notes:

Other:

Notes:

Other Income (please specify $/yr where applicable)

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Social Security:

At Age:

Employment After Retirement:

Spouse Employment After Retirement:

Other Expected Income:

Source:

Any Additional Income:

Source:

Spouse's Retirement Benefits:

Pension at age:

Lump Sum Distribution:

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