Confidential Questionnaire

Below is a form that you can fill in to provide us with some background information as we prepare to meet. Rest assured that this information is used strictly by Blankenship Financial Planning as we review your circumstances - your information never leaves our offices, except as you direct.

Before filling in this form, gather your information together. Be careful to not hit "Enter" as you navigate through the form, as this will go ahead and send the form to me. If you accidentally do it, don't worry about it - just go back (hit your "Backspace" button) and your information should still be in the form.

Please fill in the form below and click "Submit" to send the information to our office. Don't worry if you don't have exact information, "ballpark" estimates are fine at this stage - we'll get to the specifics later.

Client 1 Client 2
Name:
Email:
Phone:
Work Phone:
Cell Phone:
Birthdate:
Address:
City:
State:
Zip:
Preferred Contact Person Preferred Contact Method
Phone Email
Employer:
Title/Job:
Yrs with Employer:
Retire Date:
Salary:
Bonus/Other:
Other Income:
Total Income:

Financial Documents
Tax Return: Self Prepared Paid Preparer
Wills: Yes No Year?
Living Trusts: Yes No Year?
Power of Atty: Yes No Year?
Living Will: Yes No Year?

Client 1
Client 2
Life Insurance: Face Amt Face Amt
Health Ins: Group Indiv N/A Group Indiv N/A
Disability Ins: Group Indiv N/A Group Indiv N/A
LTC Ins: Per Day
Period
Premium 		Per Day
Period
Premium

Children/Dependents
Name Birthdate Dependent Resides (City/State)
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N

Assets
Institution Balance Annual Additions
Checking
Savings
Money Market
Retirement Plan
Retirement Plan
Traditional IRA
Traditional IRA
Roth IRA
Roth IRA
529 Plan
529 Plan
Other
Description Value
Primary Residence
Automobile
Automobile
Personal Property
Addtional Property
Other

Liabilities
Rate Balance Monthly Payment
Credit Card
Credit Card
Credit Card
Personal Loan
Student Loan
Automobile Loan
Automobile Loan
Mortgage
Home Equity Loan
Other
Please rate your working relationships with each of the following advisors:
Dissatisfied Satisfied Not Applicable
Financial Planner 1   2   3   4   5 N/A
Broker 1   2   3   4   5 N/A
Attorney 1   2   3   4   5 N/A
Accountant 1   2   3   4   5 N/A
Tax Preparer 1   2   3   4   5 N/A
Insurance Agent 1   2   3   4   5 N/A
Realtor 1   2   3   4   5 N/A
Risk Assessment
Check the appropriate boxes for each Risk Component:
Not Important Very Important
How important is capital preservation? 1 2 3 4 5 6 7
How important is growth? 1 2 3 4 5 6 7
How important is low volatility? 1 2 3 4 5 6 7
How important is inflation protection? 1 2 3 4 5 6 7
How important is current cash flow? 1 2 3 4 5 6 7
How much risk are you willing to take in order to achieve a higher return? Low      Moderate      High
1 2 3 4 5 6 7
% Enter (to the left) the Average Annual Rate of Return* you hope to earn on your portfolio to reach your financial goals.
* This rate of return is hypothetical and used for comparison purposes only. It is not related to any specific investment and there is no guarantee you will actually receive this rate.
Comment on the Advice You Seek: