OFFERING EMPLOYEE BENEFITS INTAKE FORM: EMPLOYEE STOCK OPTION PLANS

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1 - DISCLAIMER - The following form is provided by FindLaw, a Thomson Business, for informational purposes only and is intended to be used as a guide prior to consultation with an attorney familiar with your specific legal situation. FindLaw is not engaged in rendering legal or other professional advice, and this form is not a substitute for the advice of an attorney. If you require legal advice, you should seek the services of an attorney by linking to FindLaw.com FindLaw.com. All rights reserved. OFFERING EMPLOYEE BENEFITS INTAKE FORM: EMPLOYEE STOCK OPTION PLANS This document is designed to help you collect a variety of information about your company to help your attorney assess your company s situation and advise you about creating an ESOP. You should also collect the following documents (if they exist) to include in the file you will take to your attorney: Annual report (if there is one) Recent prospectus or private placement memorandum Recent financial statement Summary plan descriptions of current employee benefit plans Today s Date: GENERAL INFORMATION Name of Company: Company Address: City State Zip Contact Person: Telephone Number: Address: Name of Accountant: Telephone Number: Area Code Extension Area Code Extension BUSINESS INFORMATION What business is the company in? Business form: Corporation Partnership Sole-proprietorship

2 If your company is a corporation, in what state is the company incorporated? what kind of tax treatment does it have? C corporation S corporation Affiliated companies, parent or subsidiaries: Name of Company Relationship to Your Company STOCK INFORMATION Is your company s stock publicly traded? If yes, which stock exchange? How many shareholders are there? (Provide an estimate if your company is publicly traded.) How many stockholders hold 5% or more of the company s stock? What percentages of stock do your major shareholders own? (List from most to least (5%).) % % % % % Are major shareholders active in the business? Yes No Are family members of major shareholders active in the business If you answered Yes, what are the relationships? Stockholder Family Member Relationship _ Page 2 of 8

3 What classes of stock are outstanding? Common shares Preferred shares Other Please provide more detail about the classes of stock if appropriate. Is any sale of stock pending? Are any options or warrants outstanding? TAX INFORMATION What tax bracket is the company in this year? Federal State What bracket do you expect the company to be in next year? Federal State How is your company taxed? C corporation S corporation Other: Past taxable income and federal taxes: Net taxable income Federal taxes paid 1997 $ $ 1998 $ $ 1999 $ $ 2000 $ $ 2001 $ $ Page 3 of 8

4 Projected taxable income and federal taxes: Net taxable income Federal taxes paid 2000 $ $ 2001 $ $ 2002 $ $ 2003 $ $ EMPLOYEE INFORMATION How many employees does your company have? How may of your employees are unionized? What is the total payroll? What portion of the payroll is for unionized employees? $ $ Do you plan to include unionized employees? As a percentage, how long have your employees been with the company? 0-6 months % 6 mos. to 1 year % 1-3 years % 4-5 years % > 5 years % CURRENT KEY EMPLOYEES AND OFFICERS Name: Position: Age: Compensation:_ Stock ownership: % Name: Position: Age: Compensation: Stock ownership: % Page 4 of 8

5 Name: Position: Age: Compensation: Stock ownership: % Name: Position: Age: Compensation: Stock ownership: % POSSIBLE FUTURE KEY EMPLOYEES Name: Current Position: Potential Position: Compensation: Name: Current Position: Potential Position: Compensation: Name: Current Position: Potential Position: Compensation: EMPLOYEE BENEFITS Does your company currently have any qualified benefit plans? Page 5 of 8

6 Please provide the following information about your company s employee benefit plans. Retirement Plans 1. Kind of plan: Current assets: Current contribution: Current contribution expressed as a percentage of pay: % Type of Investments: 2. Kind of plan: Current assets: Current contribution: Current contribution expressed as a percentage of pay: % Type of Investments: 3. Kind of plan: Current assets: Current contribution: Current contribution expressed as a percentage of pay: % Type of Investments: Welfare Plans 1. Kind of plan: Benefits offered: 2. Kind of plan: Benefits offered: 3. Kind of plan: Benefits offered: Page 6 of 8

7 Does your company have any unqualified plans? If yes, what kind of plans are they and how many employees participate? 1. Kind of plan: _ Number of participants: 2. Kind of plan: _ Number of participants: 3. Kind of plan: _ Number of participants: Are any of the company s qualified plans top heavy? FINANCIAL INFORMATION Current valuation, as of : $_ Who provided the valuation of your company? Retained earnings, as of : $ WHY DO YOU WANT TO CREATE AN ESOP? To motivate employees To convert current profit-sharing plan, accounted for as an expense To obtain working capital To refinance existing debt To increase cash flow by creating tax deductions To pass control of the business To aid in estate planning To guard against corporate takeovers Other Please describe: Page 7 of 8

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