Closely Held Company Valuation Proposal Request Form

Atlantic Management Company would be happy to prepare a proposal to value your closely held company. 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 business valuation services 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.

After answering the following questions, one of our staff members will analyze the confidential data and contact you with a general business valuation assessment.

First Name:
Last Name:

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

Description of Business:

Purpose and Intended Use of the Appraisal:

Effective Date of Appraisal:

For example, date of death or alternative valuation date for estate, gifting date, or other transaction date.
To be determined

Known Deadlines or Desired Timetable:

Fiscal Year End (month/day):

Type of Corporation:

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

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

Is there Non-Voting stock?

Yes
 No

Have there been substantial, recent changes of ownership?

Yes
 No

If so, please describe:

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

Other Comments or Questions:

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.