Confidential ESOP Assessment

Atlantic Management Company would be happy to prepare a proposal to analyze your data for a general ESOP Feasibility assessment. Complete the information below and click the “SUBMIT” button found at the end of the form. In order to provide a proposal, we need to review the past 3 years of financial statements of the entity to be valued. They will be treated with complete confidentiality. You can send them to us at the address below or fax them to us at (603) 427-0146. If you are uncomfortable with this format, please give us a call at (603) 436-8009 to discuss your valuation needs in complete confidence.

Once we have received all the information necessary, a proposal will be e-mailed to you at the e-mail address you enter below. If no e-mail address is indicated, one of our analysts will follow up with you in a confidential manner. If you have questions regarding this form, please e-mail them to: amc@atlantic-mgmt.com. Thank you.

COMPLETE CONFIDENTIALITY ASSURED. All information collected from this form will be kept in the strictest confidence. The information contained herein is given only for purposes of preparing a proposal for an ESOP feasibility assessment and will not be used for any other purposes.

Please provide the requested information as completely as possible to facilitate our ability to prepare a proposal in a timely fashion. Thank you.

First Name:
Last Name:

Job Title:
Company:
Address:
 
City:
State/Province/Country:
Zip/Postal Code:
Phone:
Fax:
Website:
Email:

Description of Business:

Fiscal Year End (month/day):

Type of Corporation:

C Corporation
Professional Corporation
LLC 		S Corporation
LLP
Don't Know

Please rank your ESOP objectives in order of importance:
Selling part or all of my stock tax free: Now OR 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

The Stockholders:

Name Percent Ownership Active/Inactive Age

Is there a shareholder buy-sell agreement?

Yes No

If so, please describe:

Is there more than one class of stock?

Yes No

Would the selling shareholders consider seller financing in addition to, or in lieu of, bank financing?

Yes No

Is there Non-Voting stock?

Yes No

Have there been substantial, recent changes of ownership?

Yes No

If so, please describe:

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


Please check all that apply to your company:

Phantom Stock
Non-qualified stock options
 Stock appreciation rights
Other non-qualified employee benefit plans

The Employees:

For Prior 3 Years Number Payroll
Shareholders
Nonunion
Union
Total

Discuss any deferred compensation arrangements the company has with employees:

Revenue 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:

Balance Sheet Debt:

Outstanding Short-Term Line of Credit
Outstanding Long Term Debt

Company Value:

Book Value (Year Ended )
Outstanding Long Term Debt
Date of most recent appraisal
Equity value of most recent appraisal
Purpose of most recent appraisal

What is the company's approximate time table to complete the ESOP transaction?

What percentage of ownership would the owners like to sell to the ESOP?

To maintain a record of your proposal submission, please press the print button on your computer to print out this form.

To receive a proposal for the requested appraisal from Atlantic Management Company, please hit the “SUBMIT” button after completing this form. If we need additional information or clarification, we will call you.

If you have further questions, please e-mail us at amc@atlantic-mgmt.com or call (603) 436-8009. One of our professionals will be pleased to speak with you.