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 / Voting
Outstanding / ______/ ___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 / Social
Security Number / Annual Compensation / Eligibility
Date / Employment Date / Hours Worked / Normal
Retirement
Date / Life Insurance Coverage Within the Plan
______
______
______
______
______
______
______
______
______
______
______
______
______/ ___
___
___
___
___
___
___
___
___
___
___
___
___ / ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______

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 / Details
Group 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 / Details
Pension 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 Number
ACCOUNTANT / ______ / ______ / ______
______ / ______ / ______
______ / ______
______ / ______
______ / ______
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
______/ ______/ ______
______
______
______
______/ ______/ ______
______
______
______
______/ ______/ ______
______
______
______
______/ ______/ ______
______
______
______
______/ ______/ ______
______
______
______
______/ ______/ ______
______
______
______
______/ ______/ ______
______
______
______

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