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 us. 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 PreparedPaid Preparer
Wills: YesNo Year?
Living Trusts: YesNo Year?
Power of Atty: YesNo Year?
Living Will: YesNo Year?
Net Worth:
Liquid Net Worth:
Advisor Relationships
Please rate your working relationships with each of the following advisors:
Dissatisfied Satisfied Not Applicable
Financial Planner N/A
Broker N/A
Attorney N/A
Accountant N/A
Tax Preparer N/A
Insurance Agent N/A
Realtor N/A
Risk Assessment
Check the appropriate boxes for each Risk Component:
Not Important Very Important
How important is capital preservation?
How important is growth?
How important is low volatility?
How important is inflation protection?
How important is current cash flow?
How much risk are you willing to take in order to achieve a higher return? Low            Moderate            High

How comfortable are you with making investment decisions? Uneasy      Moderate      Confident


Investing Experience
Check the box below that best describes your investing experience:
Novice:
1-3 years experience:
4-10 years experience:
10+ years experience:
Investment Objective
Check the box below that best describes your primary investment objective:/td>
Income (capital preservation):
Income with some Growth:
Balanced Growth & Income:
Growth:
Aggressive Growth:
Very Aggressive (speculation):
%   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.
Additional Comments: