Name:
Date: / / (mm/dd/yyyy)
Age:
Tax ID Number:
Gender:  Male  Female
Smoker:  Yes  No
Name of Business:
Annual income:
Job title:
 
1. Reasons for buy/sell agreement:
  Create a market for your business interest at your death
Set a "fair value" for your interest in the business
Provide cash to your family at your death
Protect against unwanted third parties becoming owners
Prevent deadlock problems
Provide a known business continuity at an owner's death
Preserve an S-corporation status
Other reasons: (Please specify)
 
2. What type of entity is your business?
   Corporation
 C-Corporation
 S-Corporation
 Limited Liability Company (LLC)
 Partnership
 General
 Limited
 Limited Liability Partnership (LLP)
 Limited Liability Limited Partnership (LLLP)
 Sole Proprietorship
 Other form of business:(Please explain)
 
3. Ownership
Owner's name:
Percent Ownership:  %
Type of Ownership:
Family relationships to other owners, if applicable:
 
4. What events should be limited by the buy/sell agreement?
  Death of an owner
Disability of an owner
Normal retirement
Termination of employment other than by death, disability, or normal retirement
Outside third-party offer
Divorce, bankruptcy, or creditor claim against an owner
Termination of license if a professional practice
Pledging or assignment of the business interest as security for a debt
Other: (Please explain)
 
5. What events should be allowed?
  Gift to family members
Estate planning transfers (for example, revocable or irrevocable trust)
Other:(Please explain)
 
6. Who should buy the business interest?
  Other owners (cross purchase)
Employee Stock Ownership Plan (ESOP)
Should be determined at the time of the triggering event (wait and see)
Business control should pass to the other owners but the remaining interest should pass to the deceased owner's family (no-sell buy/sell)
Third party
At the triggering event
After being offered to other owners or entity first
 
7. Valuation of the business
How much is the business value?
What methods did you use to value the business?
 
8. Valuation of less than 100 percent ownership:
Should the value be reduced for any of the following:
Please Explain:
 Minority interest
  Certain events
(For example, walk away to set up a competing business)
What discount should be used?
Please Explain:

 
9. How should the business interest be sold?  Cash
 Some cash down
   and the remainder over time
   (installment sale)
How long?
What interest rate?
Restriction on transfers, dividends, etc., until the interest is fully transferred and paid?
 
10. Should the purchase be fully or partially funded by insurance if it is cost effective?
Death:  Yes    No
Disability:  Yes    No
Normal retirement:  Yes    No
 
11. What happens at the death of a business owner?
What will happen to your business or your ownership interest at your or another owners death?
 
12. Sold as a going concern:
To whom?
At what price?
How determined?
Will the buyer have funds?  Yes    No
Source:
Written agreement exist?  Yes    No
Date entered into: / /
Date last reviewed: / /
Can we have a copy of the agreement?  Yes    No
 
13. Passed to an heir or beneficiary:
Who will inherit?
Able to operate business now?  Yes    No
Able to operate business in the future?  Yes    No
When?
Who will operate business in the interim?
Do you have a specific plan to keep that person in the business?
Is adequate capital provided to accomplish transition to successor management?  Yes    No
How much?
Will any other person (for example, a spouse) need income from the business?  Yes    No
Who?
Name:
Relationship:
How much?
 
14. Liquidated:
Is cash available for an orderly liquidation?  Yes    No
Is cash available to pay business debts?  Yes    No
If business is liable?
If owners are personally liable?
Total proceeds expected from liquidation:
 
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