Business Owner  Yes  No
Business Name:
Business Address:
Business Phone:  ext 
Date of Birth: / / (mm/dd/yyyy)
Marital Status:  S  M
Spouse Date of Birth: / / (mm/dd/yyyy)
Spouse US Citizen?  Yes  No
Owner's Name:
Percent Ownership:  %
Type of Ownership:
Family relationships to other owners, if applicable:
What type of entity is your business?
Other form of business - please explain:
Do you own assets outside of the United States?  Yes  No
Do you have business interests outside the US?  Yes  No
Please explain:
Have you provided for the continuation of your business in the event of:
  Premature Death:  Yes  No
Disability:  Yes  No
Retirement:  Yes  No
Do you have a key employee(s) in your business whose loss would have a great impact on the success of your business?  Yes  No
Do you have a plan?  Yes  No
Are the key employees insured by the business?  Yes  No
Would you provide a salary to the family?  Yes  No
If so, how long?
At disability, I would like to pass my business responsibility and interest to:  Family Members
 Employee Stock Ownership Plan (ESOP)
 Potential Buyers
List names/ relationship (Rank in Order):
At retirement, I would like to pass my business interest:  Family Members
 Employee Stock Ownership Plan (ESOP)
 Potential Buyers
List names/ relationship (Rank in Order):
If I died today, I would you like to pass my business interest:  Family Members
 Employee Stock Ownership Plan (ESOP)
 Potential Buyers
List names/ relationship (Rank in Order):
Have you engaged in the financial valuation of your business using a qualified appraiser?  Yes  No
  Name Of Business Value Date Evaluated
1 / /
2 / /
3 / /
4 / /
5 / /
6 / /
7 / /
8 / /
9 / /
10 / /
Valuation of less than 100 % Ownership
Should the valuation be reduced for any of the following:
    Minority interest
    Certain events (for example, walk away to set up a competing business)
   Please explain:
What should the discount be?
   Please Explain:
How should the business interest be sold?
    Some cash down and the remainder over time (installment sale)
How long?
What interest rate?
    Restrictions on transfers, dividends, etc., until the interest is fully transferred and paid in full?
    Fully or partially funded by insurance
Sold as a going concern?  Yes  No
To whom?
At what price?
What methods were used in the valuation process?
Will the buyer have funds?  Yes    No
Does a written agreement exist?  Yes    No
Date entered? / / (mm/dd/yyyy)
Passed to an heir or beneficiary?  Yes  No
Who will inherit?
Able to operate business now?  Yes    No
Are they able to operate business in the future?  Yes    No
When? / / (mm/dd/yyyy)
Who will operate the business in the interim?
Is adequate capital provided to accomplish transition to successor management?  Yes    No
How much?
Do you have a Buy-Sell Agreement?  Yes  No
Reason to have a 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 known business continuity at an owner's death?
 Preserve an S-Corporation status?
Please Specify:
If you have a Buy/Sell Agreement, is it funded?  Yes    No
How is it funded?
Has it been updated within the past two years?  Yes    No
Have you made provisions for your business if you become sick or injured?  Yes    No
If you had a serious illness, would you have to severely reduce your lifestyle?  Yes    No
Would you object to using business dollars to provide benefits to your key employees?  Yes    No
Do you offer any benefits on a payroll deduction basis?  Yes    No
Do you offer Employee-Benefits?  Yes    No
Do you have a Tax Advantaged Retirement Plan?   Yes  No  IRA
Do you have a Tax Advantaged Retirement Plan?  Yes  No  Defined Benefit
 Target Plan
 Profit Sharing
 Money Purchase
 Cafeteria (Section 125)
Type of Plan desired?  Defined Benefit
 Money Purchase
 Profit Sharing
If 401(K), do you wish to make matching contributions?  Yes    No
Do you wish to make discretionary Profit Sharing Contributions?  Yes    No
The goal of the plan?  Favor key employees
 Treat everyone equally
Desired level of contribution:
The maximum allowed for $

Employee Census
  Name Sex

N=Non Smoker
Date Of Birth Employment Date Annual Compensation  
in Dollars

S=Spouse Only
C=Child(ren) Only
Full Time
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