Participant Questionnaire

This questionnaire must be filled out for the person who will be volunteering in the community.

Legal Name

^{LAST FIRST MI}

Date of Birth

^{Month Date Year}

Social Security Number

Marital Status [ ] Married [ ] Single

Mailing Address

City State Zip Code

School District in which you reside

Home Telephone Number ( )

Date(s) you plan to do your volunteer work: From_________To___________

Charitable/Non-Profit Organization you plan to volunteer for

Name and title of the person who will be overseeing your charitable work

Address of the Charitable Organization

Telephone Number of the Charitable Organization

Name of the Bank in which you will be depositing your Pension Checks

Address of said Bank

Type of Account: [ ] Checking [ ] Savings [ ] Money Market [ ] Other

Bank Account Number

Bank Routing Number

Please include a list of beneficiaries, their relationship to you, and their addresses. Beneficiaries are individuals who will receive the remainder of the monies in your pension fund should you pass away prior to expunging the entirety of your IRA.

At your initial client meeting, we recommend you bring either a U.S. issued Passport (expired or unexpired), or a driver’s license with either a U.S. Social Security card or original/certified copy of your birth certificate. Please also bring a voided check or bank account deposit slip.