Company Name:              

% Owned by ESOP:        

Type of corporation:

      S-Corp

      C-Corp

Fiscal Year End:              

ESOP Appraiser:             

ESOP Administrator:       

Do you anticipate future purchases of stock by the ESOP?   Yes    No

If yes, when?                    

Do you contemplate acquisitions?    Yes    No

If yes, will you do them through the ESOP?    Yes    No

Are you currently a member of The ESOP Association?      Yes    No          NCEO?   Yes    No

ESOP Trustee:                

Other Information (i.e. corrected/updated address information, etc.):