ESOP Advisors and Bankers
The purpose of this questionnaire is to help us determine the feasibility of an Employee Stock Ownership Plan for your company. Any figures in response to these questions will be held in strictest confidence and will not be disclosed to anyone without your express consent.
You shall be under no obligation to pay any fees or charges as a result of your furnishing this preliminary information. Fees or other charges are only payable pursuant to and upon the execution of a formal agreement.
Please print out this form, complete all applicable entries, and then mail or fax your completed questionnaire to the attention of Jeannie Kluga at our San Francisco office. A representative will contact you shortly thereafter to discuss the feasibility of an ESOP for your company.
Company Name:
_____________________________________________________________________________
Address:
_____________________________________________________________________________
City/State/Zip:
_____________________________________________________________________________
Person to contact/Title:
_____________________________________________________________________________
Phone:
______________________________________
Fax:
______________________________________
Description of Business Activity:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Fiscal Year End:
_______________________________________
[ ] C-Corporation? or
[ ] S-Corporation
Please check your ESOP objectives and rank in order of importance:
________ Selling part or all of my stock tax free: [ ] now [ ] within 10 years
________ Buying back stock from other shareholders with tax deductible dollars.
________ Increasing the value of the stock that I keep.
________ Cutting corporation taxes and increasing cash flow.
________ Increasing employee incentive and productivity.
Stockholders / Shares (Percent) / Active or Inactive / Age
_____________________ / ________________ / ______________ / ________
_____________________ / ________________ / ______________ / ________
_____________________ / ________________ / ______________ / ________
Existing Qualified Benefits Plans:
[ ] 401(k)
[ ] Profit Sharing Plan
[ ] Other
How many employees:
_________________
Approximate annual payroll:
_________________
Approximate revenues:
Last year: $______________
This year: $____________
Approximate pre-tax earnings
Last year: $______________
This year: $____________
Estimated debt: $______________________
Estimated company value: $____________________________