We will develop a confidential preliminary analysis for you. This is free of charge.
Fill out the following questionnaire, print, and fax to us at 434-286-3815 or email to esop@esopservices.com
CONFIDENTIAL ESOP PRELIMINARY ASSESSMENT QUESTIONNAIRE
Does your company qualify for an ESOP (Employee Stock Ownership Plan)? Can your shareholder, corporate, and management objectives be addressed by an ESOP?
By answering the questions listed below, and return the questionnaire by e-mail (save as a word document) or fax, we will provide you with preliminary analysis at no cost.
Company Information:
Company Name: __________________________________________________________________________
Mailing Address: _________________________________________________________________________
City, State, Zip Code: _______________________, ________, __________
Street Address (for overnight delivery purposes): _______________________________________________
City, State, Zip Code: _______________________, ________, __________
Telephone Number: _____________________ FAX Number: ________________________
E-mail: ________________________________ Web site Address:
Person(s) to contact regarding this information:
Name: __________________________________ Name: __________________________________
Title: __________________________________ Title: __________________________________
Principal business activity: ______________________________________________
How many locations?: _____________________ Yrs. in business? ______________
Names of Subsidiaries and Locations: ______________________________________________
State where incorporated: ______________ Fiscal Year End: ______________
Type of Corporation: ___ C Corporation ___ Subchapter S Year of Incorporation
Is stock publicly traded?: Yes No If yes, where?
Most recent valuation of business, as of: _________ ; Value: _______________
Determined by whom?________________________________________________
Current year projected earnings pre-tax: $______________________________
Last year’s pre-tax: $ ______________________________
Next year’s projected pre-tax earnings: $______________________________
1. How did you hear about us? Conference/Workshop Internet Other
Personal reference by ______________________________
2. Employee Information:
Number of Annual
Employees Payroll
Salaried: _________ _________
Hourly Non-Union: _________ _________
Hourly Union: _________ _________
3. Stock Information:
Number of stockholders (estimate for public): _________
Number of “5% or greater” stockholders: _________
Percentages of stock owned by major shareholder(s): _________
Classes of stock: _________
Number of shares outstanding for each class: ________________
Are any stock sales pending?: _________
Are major stockholders active in the business?: Yes No
Are family members of major stockholders active in the business?: Yes No
If so, please specify relationships (spouse, son, daughter, etc.): _________________________________
__________________________________________________________________________________
4. Tax Rate Information, if C, Corporate Rate; S, Personal Rate:
Federal State
Last Year: ________________ ________________
Current Year: ________________ ________________
Next Year: ________________ ________________
5. Employee Benefit Plan Information:
Please provide the following information for your existing tax-qualified plans:
Most Recent Annual Current Employer-
Employer Contributions ($) Contributed Assets ($)
Profit Sharing Plan ________________ ________________
401(k) Plan ________________ ________________
Defined Benefit Plan ________________ ________________
Under funded: Yes No Over funded: Yes No How much?
Other: ______________________________________________________________
Any of the above plans top-heavy?: Yes No Not Sure
Do you currently have any type of stock bonus, purchase, option or synthetic equity plans in place?
______________________________________________________________
If so, please provide a description: ______________________________________________________________
6. Principal Objectives For Considering An ESOP (Please Rank 1, 2, etc. or N/A):
___ “Tax-free” Liquidity ___ Perpetuation
___ Going Private ___ Tax-Free S Corporation Income
___ Estate Planning ___ Corporate Divestiture or Acquisition
___ Employee Retention & Motivation ___ Charitable Giving
___ Increase Working Capital
Please describe any intended ESOP transaction currently under consideration. Please provide any additional information that would be helpful:
7. Key Advisors:
Accountant: _________________________________________________________
Attorney: _________________________________________________________
Principal Bank: _________________________________________________________
Insurance Agent: _________________________________________________________
8. OPTIONAL Preliminary Assessment Cash Flow and Tax Savings Estimate
We have a model which illustrates the projected tax savings and cash flow of an ESOP transaction on a preliminary basis. If you would like this additional analysis please provide the following information for the next seven years. A rough estimate, and growth rates are acceptable for this level of analysis.
- Pre-tax income (before 401(k) match or Profit Sharing Plan Contribution
- 401(k) match
- Other significant Income/ (Expenses)
- Cash at the beginning of the current year
- Deprecation
- Non-ESOP Debt Amortization (Principle Payments)
- Capital Expenditures
- Growth rate for payroll provided in #2 above
- Most recent financial statements (not required, but is helpful)
Confidentiality Agreement
ESI agrees that any non-publicly disclosed data provided by ___________________ or other parties in connection with ESI’s work hereunder is proprietary and belongs to ___________________ and is highly confidential, and will not be disclosed, directly or indirectly, to third parties without ___________________ 's advance written consent, even after the completion of this project, unless required by law.
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