DOCUMENTS CURRENTLY EXECUTED OR FILED

(Please provide us with a copy)

CHILDREN OR OTHER DEPENDENTS

(Use full legal name. Use “JT” if both spouses are the parents, “H” if husband is the
parent, “W” if wife is the parent, and “A” if the child has been legally adopted - indicating
adopted by whom).

GRANDCHILDREN

(Use full legal name and indicate what child of yours is the parent)

ADVISORS

EXECUTORS AND TRUSTEES

(Please name Executors for your will, and Trustees for your trust, as well as contingent
choices)

INVESTMENT ACCOUNTS

TYPE: Money market “MM”, investment “I”, cash management “CM”, or other account that
is in a street name (indicate type below). Include securities held by stock brokerage or
other institutions. Include securities held by stock brokerage or other institutions.

PERSONAL EFFECTS

TYPE:Major personal effects such as motor vehicles, boats, jewelry, club
memberships, collections, antiques, furs, household furnishings, and all other valuable
nonbusiness personal property (indicate type below and give a lump sum value for miscellaneous,
less valuable items).

LIFE INSURANCE, LONG TERM CARE INSURANCE AND ANNUITIES

OTHER ASSETS

TYPE: TYPE: Other property is any property that you have that does not fit into any
category, including trusts, investment partnership and limited liability company interests,
anticipated inheritances, gifts or lawsuits..

SUMMARY OF VALUES

• Joint Tenancy (JT), Tenancy in Common (TC) and Community Property (CP) values go
½ in husband’s column, ½ in wife’s column, assuming there is no third party
ownership interest. If the other owner is not your spouse, put your interest in jointly
held property in the single column.

Additional Information

2. Have you ever lived in a community property state? (Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin). If so, please name.

3. Have either you or your spouse been married previously? Please provide a copy of
any divorce decree or prenuptial agreement.

4. Have you made gifts of $10,000 or more to any person (other than your spouse) in
any one year? If you have filed a gift tax return, please provide a copy of the most recent
return.

5. If you own joint tenancy property with someone other than your spouse, whose funds
were used to purchase the property?

6. Estimated inheritance, if any ?

7. Are you or any member of your immediate family a beneficiary or trustee of any
trust?

8. Do you anticipate any business or professional changes in the next 12 months?

9. Special family needs (support of a parent or child, special education, physical or
mental handicap):

10. Do you own any property for your children, such as under a Uniform Transfer to
Minor’s Act?

11.Briefly describe your estate planning goals:

12. Potential Lawsuits (As Plaintif or Defendant)

13.Health Status of Client, Spouse, and/or Parents (Good/Fair/Poor etc.)

14. Mental Health Status (Capacity Issues)

CERTIFICATION

The undersigned hereby represents to Fox & Moghul, and each of its attorneys, that the
information contained in this intake form is accurate and complete, and that the undersigned
understands that the law firm and its individual lawyers will rely on this information. I
understand that if the information contained herein is inaccurate or incomplete, the
recommendations made by the law firm may not be appropriate.