We will develop a confidential preliminary analysis for you, free of charge.
Fill out the following questionaire, print and fax to us at 434-286-3815.
A downloadable Microsoft Word version, which can be completed and saved to your desktop, is available by clicking here. Please email the competed form to esop@esopservices.com
CONFIDENTIAL Preliminary Assessment Questionaire
Company Name:
Mailing Address:
City: State: Zip Code:
Street Address (for Overnight Delivery):
Telephone Number:
Fax Number:
E-mail Address:
Person(s) to Contact regarding this information:
Name: Title:
Name: Title:
Principal Business Activity:
How many locations?: Years in Business?:
Names of Subsidiaries and Locations:
State where incorporated?: Fiscal Year End:
Type of Corporation:
- C Corporation
- Subchapter S
Is Stock publicly traded?: Yes No
Privately held? Yes No
Most recent valuation of business: Date: Value:
Determined by whom?:
Current year projected earnings pre-tax:
Last year’s pre-tax:
Next year’s projected pre-tax earnings:
- How did you hear about us?
- Conference/Workshop
- Internet
- Personal Reference by:
- Other:
- Employee Information
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Number of Employees
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Annual Payroll
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Salaried:
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Hourly Non-Union:
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Hourly
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- Stock Information
Number of stockholders (estimate for public):
Number of "5% or greater" stockholders:
Percentages of stock owned by major stockholder(s):
Classes of stock:
Are any stock sales pending?:
Are major stockholders active in the business?: Yes No
If so, please specify relationships (spouse, son, daughter, etc.):
- Corporate Tax Rate Information
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Federal
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State
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Last Year:
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Current Year:
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Next Year:
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- Employee Benefit Plan Information
Please provide the following information for your existing tax-qualified plans:
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Most Recent Annual Employer Contributions ($)
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Current Employer Contributed Assets ($)
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Profit Sharing Plan:
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401(k) Plan:
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Defined Benefit Plan:
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Other:
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Any of the above plans top-heavy?: Yes No Not Sure
Do you currently have any type of stock bonus, purchase, or option plans in place?
If so, description:
- Principal Objectives For Considering an ESOP (Please Rank)
- "Tax-Free" Liquidity
- Perpetuation
- Increase Working Capital
- "Tax-Free" S Corporation Income
- Estate Planning
- Corporate Divestiture or Acquisition
- Charitable Giving
- Employee Retention & Motivation
Please describe any intended ESOP transactions currently under consideration:
- Key Advisors
Accountant:
Attorney:
Principal Banker:
Insurance Agent:
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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