Client Services

ESOP Feasibility

Complimentary ESOP Analysis:

The purpose of this questionnaire is to help us determine the feasibility of an Employee Stock Ownership Plan for your company.

Any figures furnished 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 supplying this preliminary information. Fees or other charges are only payable pursuant to and upon the execution of a formal agreement.

After you complete this questionnaire and send it to us, one of our professionals will review your information and contact you within 72 hours to let you know our findings.

To read more about the steps and components of our initial feasibility analysis go to the ESOP Assessment page under Client Services.

1. COMPANY INFORMATION

Company Name

Address

City

State	Zip

Contact Person

Title

Phone

Fax

Website

2. DESCRIPTION OF BUSINESS

3. FISCAL YEAR END

4. TYPE OF COMPANY

C Corporation S Corporation Professional Corporation LLP LLC

5. PLEASE RANK YOUR ESOP OBJECTIVES IN ORDER OF IMPORTANCE

Selling part or all of my stock tax free: Now Within Years Buying back stock from other shareholders with tax deductible dollars Increasing the value of the stock that I keep Cutting corporate taxes and increasing cash flow Increasing employee incentive and productivity

6. THE STOCKHOLDERS

Name	Percent Ownership	Active/Inactive	Age






Is there a shareholder buy-sell agreement?YesNo
Have there been substantial, recent changes of ownership?YesNo
If so, please describe

7. EXISTING IRS-QUALIFIED EMPLOYEE BENEFIT PLANS

TYPE OF PLAN	NUMBER OF EMPLOYEES INCLUDED	TYPICAL ANNUAL CONTRIBUTION	ACCUMULATED FUNDS
Profit Sharing
401(k) - Employee Deferral
401(k) - Employer Match *
Other

* Describe 401(k) matching formula

8. THE EMPLOYEES

For Prior Fiscal Year:	NUMBER	PAYROLL
Shareholders
Nonunion
Union
Total

9. REVENUES AND PRE-TAX EARNINGS

For Prior 3 Years	REVENUES	PRE-TAX EARNINGS	EBITDA
Year Ended:
Year Ended:
Year Ended:
Projected for Current Fiscal Year

Please describe and provide the amount of any unusual items or non-recurring expenses that, if added back to pre-tax income, would provide a more accurate indication of the company's true earnings capacity:

10. BALANCE SHEET DEBT

Outstanding short-term Line of Credit
Outstanding Long Term Debt

11. COMPANY VALUE

Book Value (Year Ended ):
Estimated Current Market Value
Date of most recent appraisal
Equity Value of most recent appraisal

Purpose of most recent appraisal