Preliminary ESOP Analysis Questionnaire

The purpose of this questionnaire is to help us determine the preliminary viability of an Employee Stock Ownership Plan for your company. All responses will be held in strictest confidence and will not be disclosed to anyone outside our firm without your expressed consent.

You shall be under no obligation to pay any fees as a result of your furnishing this information. Fees would only be payable pursuant to the execution of a formal agreement, if any.

Please complete all applicable entries, and hit the submit button at the bottom of the page. One of our Managing Directors will contact you shortly thereafter to discuss how ESOPs are designed and how they may be useful to your situation.

First Name:
Last Name:
Company:
Address:
City:
State:
Postal Code:
Country:
Phone:
e-Mail:
Description of Business:
Fiscal Year End (month/day):
Type of Corporation:
In which state is the company headquartered?
Please review these ESOP objectives and rank in order of importance from the viewpoint of the majority owner(s)
a - Selling part or all of my stock tax free now
b - Selling part or all of my stock tax free within 10 years
c - Buying back stock from other shareholders with tax deductible dollars
d - Increasing the value of the stock that I keep
e - Cutting corporation taxes and increasing cash flow
f - Increasing employee incentive and productivity
Please list all Stockholders / Shares (Percent) / Title or Inactive / Age
Do you have a profit sharing program?
What is the total payroll?
Is there a shareholder buy-sell agreement?
Is there more than one class of stock?
Is there voting and non-voting stock?
Have there been substantial, recent changes of ownership?
If so, please describe:
Do you have a 401k program?
If yes, does is there a company match?
Do you have a SEP?
If yes, what kind?
Equity Value of Most Recent Appraisal
Date of Most Recent Appraisal
Employee Information
Total Number of Full Time Employees (W-2 employees with more than 1,000 hours of annual service)
How many shareholders are also employees?
How many employees belong to a Union?
Do any of these employees work for foreign subsidiaries?
Number of locations
For this fiscal year and last fiscal year, please indicate approximate revenues, & pre-tax earnings.
Please describe and provide the amount of any unusual items or non-recurring expenses that, if added back to pre-tax income, would provide a more accurate indication of the company's true earnings capacity:
Balance Sheet Debt:
Outstanding short term Line of Credit:
Outstanding long term Debt (include current portion):
Do you have a cash bonus program?
Your Estimate of Total Company Value
Do you have a Model SEP?
Purpose of Most Recent Appraisal
Company Value
Do you have other Qualified Retirement Programs?
If yes, what kind?
Do you have a Simple IRA?
Any Additional Comments?