Deferred Compensation Request Form

Please complete the following request form to receive FREE information on Deferred Compensation. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Home Phone:   
  Work Phone: 
  Employer's Name:          
  Employee's Name:          
  Employee's Position:      
  Employee's Date of Birth: 
     Yes    No   
  Employee's tax bracket is:
     28%    31%    36%    39.6%    Unknown
  Amount of anticipated annual deferral:         
  Expected Number of years of deferred payments: 
  Expected Number of years until retirement:     
  What is the possible time frame for implementing such a program?
     Less than one month    1 to 3 months    3 to 6 months
  Your general awareness on this subject is:
  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
  Additional Comments/Questions:


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All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.