Business Financial Planning
Data Questionnaire
Provided By: KJH Financial Services
BUSINESS INFORMATION
Full Legal Name of Business ______
Address ______
Phone Number ______
Fax Number ______
Principal Business Activities ______
Employer Identification Number ______
Form of Business Entity
______/ Sole Proprietorship / ______/ Non-Profit Organization______/ General Partnership / ______/ Professional Corporation
______/ Limited Partnership / ______/ Limited Liability Company
______/ C Corporation / ______/ Other
______/ Subchapter S Corporation
Accounting Basis:Cash ______Accrual ______
Date Business Began ______
Date of Incorporation ______
State of Incorporation ______
Fiscal Year Ends ______
Related Corporations or Entities (Names, nature of enterprises, relationship of enterprises)
______
______
______
Capitalization
Number of Common Shares / Voting / Number of Preferred Shares / Voting / Other / VotingOutstanding / ______/ ___Y_N__ / ______/ ___Y_N__ / ______/ ______
Authorized / ______/ ______/ ______/ ______/ ______/ ______
Dividend Rate / ______/ ______/ ______/ ______/ ______/ ______
DISTRIBUTION OF OWNERSHIP
Name of Owner / Birthdate / Date Employed / Employment Agreement / Position / Salary / Bonus / Currently Active______/ ______/ ______/ _Y_N______/ ______/ $______/ $______/ _Y_N______
______/ ______/ ______/ _Y_N______/ ______/ $______/ $______/ _Y_N______
______/ ______/ ______/ _Y_N______/ ______/ $______/ $______/ _Y_N______
______/ ______/ ______/ _Y_N______/ ______/ $______/ $______/ _Y_N______
______/ ______/ ______/ _Y_N______/ ______/ $______/ $______/ _Y_N______
Common / Preferred / Other
Name of Owner / Number of Shares / Purchase Date / Cost / Number of Shares / Purchase Date / Cost / Number of Shares / Purchase Date / Cost
______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______
OTHER KEY EMPLOYEES
Name / Birthdate / Date Employed / Employment Agreement / Position / Salary / Bonus______/ ______/ ______/ __Y__N______/ ______/ ______/ ______
______/ ______/ ______/ __Y__N______/ ______/ ______/ ______
______/ ______/ ______/ __Y__N______/ ______/ ______/ ______
______/ ______/ ______/ __Y__N______/ ______/ ______/ ______
______/ ______/ ______/ __Y__N______/ ______/ ______/ ______
______/ ______/ ______/ __Y__N______/ Personnel Mgr. / ______/ ______
______/ ______/ ______/ __Y__N______/ Controller / ______/ ______
CENSUS FORM
FOR
______
______
Name / Sex / Birthdate / SocialSecurity Number / Annual Compensation / Eligibility
Date / Employment Date / Hours Worked / Normal
Retirement
Date / Life Insurance Coverage Within the Plan
______
______
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LOANS
(Complete one page for each loan. Do not include credit cards.)
Asset Description (If applicable) / ______Borrower(s) (Is loan personally guaranteed by
anyone? If so, whom?) / ______
Type of Loan (Plant & Equipment, Lines of
Credit, etc.) / ______
Balance Outstanding / $______
Last Annual Reset Balance Date
(Variable Rate Only) / ______
Original Amount Borrowed / $______
Minimum Payment
(If mortgage, exclude taxes and insurance) / $______
Actual Payment / $______
Frequency of Payment / ______
Date of 1st Payment / ______
Issue Date / ______
Maturity Date / ______
Current Interest Rate / ______
Institution (Bank, S&L, etc.)______
Address______
______
______
Phone______
Loan Account No.______
Comments______
______
______
______
LOANS
(Complete one page for each loan. Do not include credit cards.)
Asset Description (If applicable) / ______Borrower(s) (Is loan personally guaranteed by
anyone? If so, whom?) / ______
Type of Loan (Plant & Equipment, Lines of
Credit, etc.) / ______
Balance Outstanding / $______
Last Annual Reset Balance Date
(Variable Rate Only) / ______
Original Amount Borrowed / $______
Minimum Payment
(If mortgage, exclude taxes and insurance) / $______
Actual Payment / $______
Frequency of Payment / ______
Date of 1st Payment / ______
Issue Date / ______
Maturity Date / ______
Current Interest Rate / ______
Institution (Bank, S&L, etc.)______
Address______
______
______
Phone______
Loan Account No.______
Comments______
______
______
______
LOANS
(Complete one page for each loan. Do not include credit cards.)
Asset Description (If applicable) / ______Borrower(s) (Is loan personally guaranteed by
anyone? If so, whom?) / ______
Type of Loan (Plant & Equipment, Lines of
Credit, etc.) / ______
Balance Outstanding / $______
Last Annual Reset Balance Date
(Variable Rate Only) / ______
Original Amount Borrowed / $______
Minimum Payment
(If mortgage, exclude taxes and insurance) / $______
Actual Payment / $______
Frequency of Payment / ______
Date of 1st Payment / ______
Issue Date / ______
Maturity Date / ______
Current Interest Rate / ______
Institution (Bank, S&L, etc.)______
Address______
______
______
Phone______
Loan Account No.______
Comments______
______
______
______
LOANS
(Complete one page for each loan. Do not include credit cards.)
Asset Description (If applicable) / ______Borrower(s) (Is loan personally guaranteed by
anyone? If so, whom?) / ______
Type of Loan (Plant & Equipment, Lines of
Credit, etc.) / ______
Balance Outstanding / $______
Last Annual Reset Balance Date
(Variable Rate Only) / ______
Original Amount Borrowed / $______
Minimum Payment
(If mortgage, exclude taxes and insurance) / $______
Actual Payment / $______
Frequency of Payment / ______
Date of 1st Payment / ______
Issue Date / ______
Maturity Date / ______
Current Interest Rate / ______
Institution (Bank, S&L, etc.)______
Address______
______
______
Phone______
Loan Account No.______
Comments______
______
______
______
FUTURE BUSINESS PLANS
Where is the business going? ______
______
Are there any plans to go public? ______
______
If so, when? ______
Are there any material acquisitions or dispositions anticipated in the next few years? ______
______
Are there any new product lines or services, which will be provided and will change your profit structure?
______
______
Will there be any material capital requirements in the next few years?
______
______
Have you formally put together a business plan?
______
If so, for how long of a period? ______
What is your anticipated rate of growth in sales profits?
______
______
What are the most important factors in making your business successful?
______
______
______
How many additional employees do you anticipate adding and in what areas of the business?
______
______
Are any of your employees unionized? Give details. ______
______
FUTURE BUSINESS (cont.)
Is there any current attempt by your employees to become unionized? Give details.
______
______
What has been the company’s policy concerning salary increases, bonuses and employee fringe benefits?
______
______
What has been your rate of employee turnover? ______
______
Do you presently have an accumulated earnings tax problem? (C Corporations Only)
______
Do you have any loss carry forwards available?
______
______
Is any property owned by the shareholders being leased to the business?
______
______
______
Have any reorganization plans been implemented or are about to be implemented because
of the planned retirement, death, disability, divorce, bankruptcy, or estate tax problems of one of the owners? ______
______
BUSINESS CONTINUATION
Do you want your business interest retained or sold if you:
Owner / Insurable / Retire? / Become Disabled? / Die? / Other?______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______/ ______
If the business interest is retained, who will end up with each owner’s interest and how will they acquire it? Also, who will replace you in your job?
Owner / New Owner of Interest / Method of Acquisition / Replacement______/ ______/ ______/ ______
______/ ______/ ______/ ______
______/ ______/ ______/ ______
______/ ______/ ______/ ______
______/ ______/ ______/ ______
If sold, list the purchaser, purchase price and funding arrangement.
Owner / Purchaser / Price / Funding Arrangement______/ ______/ ______/ ______
______/ ______/ ______/ ______
______/ ______/ ______/ ______
______/ ______/ ______/ ______
______/ ______/ ______/ ______
BUSINESS CONTINUATION (cont.)
Is there Key person insurance on all key owners and employees?
______
______
Estimate the lowest price for which the entire business might be sold as a going concern today.
______
What would you sell your interest for?
______
Does a buy-sell agreement exist?
______
If a buy-sell agreement does not exist, how do you intend to dispose of your interest?
______
______
Type of agreement: (Circle One) / ...... / Cross Purchase...... / Stock Redemption/Entity Purchase
...... / Combination
Method for determining value: (Circle One)Book Value$______
Earnings Multiple$______
Appraisal$______
Agreed Value$______
Other$______
How is the agreement funded and for what amount?
______
______
Will the business have to be liquidated upon your death?
______
______
Have you purchased disability overhead insurance?
______
______
EMPLOYEE BENEFITS
Department Head: ______Phone: ______
Does your company provide any of the following?
Benefit / Employees Covered / DetailsGroup Term Insurance / ______/ ______
Split Dollar Insurance / ______/ ______
Accident Insurance / ______/ ______
Medical Insurance / ______/ ______
Medical Reimbursement / ______/ ______
Dental Care / ______/ ______
Vision Care / ______/ ______
Sick Pay Plan / ______/ ______
Long-Term Disability Insurance / ______/ ______
Company Car or Van / ______/ ______
Club Memberships / ______/ ______
Educational Reimbursement Plan / ______/ ______
Group Legal Service Plan / ______/ ______
Financial Planning Services / ______/ ______
Child or Dependent Care Assistance / ______/ ______
Other: / ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
Have you established a Cafeteria Benefits Plan?
______
______
RETIREMENT PLANS
Benefit / Employees Covered / DetailsPension Plan / ______/ ______
Profit-Sharing Plan / ______/ ______
SEP / ______/ ______
SAPSEP / ______/ ______
401(k) Plan / ______/ ______
401(a) Savings Plan / ______/ ______
Employee Stock Ownership Plan (ESOP) / ______/ ______
Non-Qualified Deferred Compensation Plan / ______/ ______
Incentive Stock Options / ______/ ______
Non-Qualified Stock Options / ______/ ______
Stock Appreciation Rights / ______/ ______
Performance Units / ______/ ______
Employee Stock Purchase Plan / ______/ ______
Stock Bonus Plan / ______/ ______
Restricted Stock Plan / ______/ ______
Phantom Stock Plan / ______/ ______
Formula Price Shares / ______/ ______
Salary Continuation After Death / ______/ ______
ADVISOR QUESTIONNAIRE
Name / Firm & Address / Phone/Fax NumberACCOUNTANT / ______ / ______ / ______
______ / ______ / ______
______ / ______
______ / ______
______ / ______
RETIREMENT PLAN / ______ / ______ / ______
ADMINISRATOR/ACTUARY
(if you own a business) / ______ / ______ / ______
______ / ______
______ / ______
______ / ______
ATTORNEY / ______ / ______ / ______
______ / ______ / ______
______ / ______
______ / ______
______ / ______
BANKER - / ______ / ______ / ______
(loans) / ______ / ______ / ______
______ / ______
______ / ______
______ / ______
INSURANCE AGENT - / ______ / ______ / ______
(Life & Disability) / ______ / ______ / ______
______ / ______
______ / ______
______ / ______
INSURANCE AGENT - / ______ / ______ / ______
(Property & Casualty) / ______ / ______ / ______
______ / ______
______ / ______
______ / ______
ADVISOR QUESTIONNAIRE (cont.)
EMPLOYEE BENEFITS - / ______ / ______ / ____________ / ______ / ______
______ / ______
______ / ______
______ / ______
OTHER / ______ / ______ / ______
______ / ______ / ______
______ / ______
______ / ______
______ / ______
OTHER / ______ / ______ / ______
______ / ______ / ______
______ / ______
______ / ______
______ / ______
BOARD OF DIRECTORS
What are your annual directors’ fees per director? $______
Name / Address / Phone Number______/ ______/ ______
______
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______
______/ ______/ ______
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CHECKLIST OF DATA/DOCUMENTS
Tax and Financial Information (3 years)
______Tax Returns for all Affiliates
______Financial Statements
______Copy of Your Latest Business Plan
______Loan Agreements
______Lease Agreements
______Corporate Minutes and Communications
______Investment Confirmations for All Corporate Investments
Retirement and Compensation Plan Documents
______Qualified Plan Documents
______Non-Qualified Deferred Compensation Agreements
______Employment Agreements
______5500 Federal Tax Forms (3 years)
______Personal Services Contracts
______Investment Confirmations for Qualified and Non-Qualified Plans
Employee Benefits
______Medical Plan Information
______Disability Plan Information
______Life Insurance Plan Information
______Split Dollar Insurance Policies
______Latest Billing Statements for All Employee Benefits
______Copies of All Employee Benefit Books and Brochures
Ownership Transfer Information and Insurance Policies
______Listing of All Owners and the Percentage of Ownership
______Copies of All Buy-Sell Agreements
______Information on Funding Arrangements and All Insurance Policies
______Disability Overhead Insurance Policies
______Key Person Life Insurance Policies
______Property and Casualty Insurance Policies