<p> Roth IRA Conversion Form 1. Client Information First Middle Last</p><p>Gender Age Date of Birth (M/D/Y) Assumed Age at Death</p><p>Address</p><p>City State Zip Code</p><p>Phone Email</p><p>2. Spouse Information Spouse? First Middle Last Yes No Gender Age Date of Birth (M/D/Y) Assumed Age at Death</p><p>3. Dependent Children Children? Name Gender Date of Birth (M/D/Y)</p><p>Yes No Name Gender Date of Birth (M/D/Y)</p><p>Name Gender Date of Birth (M/D/Y)</p><p>Name Gender Date of Birth (M/D/Y)</p><p>4. Client Income Information Amount ($) Increase (%) From (age) To (age) Social Security Defined Benefit Plans Wages Annuity Other</p><p>5. Spouse Income Information Amount ($) Increase (%) From (age) To (age) Social Security Defined Benefit Plans Wages Annuity Other Roth IRA Conversion Form cont. 6. Tax Assumptions □ Single Itemized Deductions (excluding mortgage interest) □ Married Filing Jointly Filing Status: Amount ($) □ Married Filing Separately □ Head of Household</p><p>7. Assumed Future Tax Law Changes Percent (%) Tax Bracket Inflation Adjustment Percent (%) Year Tax Bracket Percentage Change</p><p>□ Proposed 28% Limit on Itemized Deductions □ Proposed Health Care Surcharge</p><p>8. Asset Information Rate of Cost To Deposit Fro To Account Withdrawal Increase From Increase Return Basis (age Amount m (age Value ($) Amount ($) (%) (age) (%) (%) ($) ) ($) (age) ) Savings, Money Markets</p><p>CDs, Bonds</p><p>Non-Qualified Annuities IRA, 401(k), 403(b) Plans</p><p>Roth IRA</p><p>Stocks, Investments □ Reinvest RMD for IRA, 401(k), or 403(b) Plans 9. Residence Information Residence Mortgage Equity Line of Credit Current Value ($) Balance ($) Current Value ($)</p><p>Appreciation Rate (%) Interest Rate (%) Appreciation Rate (%)</p><p>Purchase Price Monthly Payment Purchase Price</p><p>10. Client Main Objective □ Higher After-Tax Income □ Higher Personal After-Tax □ Larger Estate for Posterity for Spouse Income □ Other ______</p>