ESOP Feasibility Questionnaire

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:(____)______________


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


____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:



Principal Bank:________________

Insurance Agent:_______________