Does your company qualify for an ESOP? By answering the questions listed below, we will provide you with preliminary analysis at no cost.
*Please print this form, fill out, and fax to (817)581-0192 Attn: Steve Allison
Company Information
Company Name:_____________________________________
Mailing Address:_____________________________________
City, State, Zip Code:_________________________________
Telephone Number:(____)_______________
Fax Number:(____)______________
Email:__________________________________
Website Address:_________________________
Contact Person(s) regarding this information:
Name:____________________ Title:____________________
Name:____________________ Title:____________________
Principal Business Activity:____________________________
Number of Locations:________ Years in Business:_________
Names & Locations of Subsidiaries:_____________________
___________________________________________________
State Where Incorporated:________ Fiscal Year End:______
Type of Corporation: __C Corporation __Subchapter S
Is Stock Publicly Traded?__no __yes If yes, where?_______
Most Recent Valuation of Business, as of:____ Value:______
Determined by Who?________________________________
Current Year Projected Earnings Pre-tax:___________
Last Year's Pre-tax:____________
Next Year's Projected Pre-tax Earnings:_____________
How Did You Hear About US?______________________
Employee Information:
# of employees annual payroll
Salaried ________ ________
Hourly Non-union ________ ________
Hourly Union _________ ________
Stock Information:
Number of Stockholders (estimate for public):____________
Number of "5% or Greater" Stockholders:_______________
Percentages of Stock Owned by Major Shareholders:______
___________________________________________________
Classes of Stock:____________________________________
Number of Shares 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):_______________________________________________
Tax Rate Information, if C, Corporate Rate, S, Personal Rate: Federal State
Last Year: ______ ______
Current Year: ______ ______
Next Year: ______ ______
Employee Benefit Plan Information
-please provide the following information for your existing tax-qualified plans:
Most recent contribution Current Contribution
Profit Sharing Plan: _______ _______
401(k) Plan: _______ _______
Defined Benefit Plan: _______ _______
Under Funded:_____ Over Funded:_____ 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:_______________________
Principle Objective for Considering An ESOP(rank 1, 2, etc. of NA)
____"Tax-free" Liquidity
____Estate Planning
____Going Private
____Employee Retention & Motivation
____Increase Working Capital
____Perpetuation
____Tax-free S Corporation Income
____Corporate Divestiture or Aquisition
____Charitable Giving
*Please describe any intended ESOP transaction currently under consideration. Please provide any additional information that would be helpful:
Key Advisors:
Accountant:__________________
Attorney:____________________
Principal Bank:________________
Insurance Agent:_______________
