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