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[NAME OF LAW FIRM] New Client Report Date: [date of report] Full Client Name: [name of client] Type

of Entity: [type of entity] Mailing Address: [mailing address of entity] Telephone: [telephone number] Fax: [fax number] Timeslips Data: Names: Matters: 1. 2. 3.

Client Nickname: [name] Client Number: [number] [Name] [Name] [Name]

Billing rate levels: Atty rate level $[dollar amount] or client rate per hour: $[dollar amount] Source atty: [name] Responsible atty: [name] Billing atty: [name] Referred by: [name] Billing type: _______ Contingent: _______ Monthly: _______ Flat fee: _______ Describe services to be rendered: [description of services] . Include client on firm mailing for _______ announcements; _______ holiday cards; _______ calendars; _______ holiday reception; _______newsletters; _______ other materials. Engagement letter sent on: [date] Received on: [date] Retainer requested for services: $[dollar amount] ; For costs: $[dollar amount] . For client: names of client, principals, affiliates and representatives of client (principal owners, officer, directors, top managers, subsidiaries, probable witnesses): (attach supplement if necessary): [names] . For adverse party: Names of adverse party, principals, affiliates and representatives of client (principal owners, officers, directors, top managers, subsidiaries, and probable witnesses): (attach supplement if necessary): [name(s)] . I have reviewed this new client report and am not aware of any possible conflict of interest, except as indicated below: [description] . Attorney Initials Date Reviewed ____________ [date 1] ____________ [date 2] ____________ [date 3] ____________ [date 4]