Hitchner James, Mard Michael. Financial Valuation Workbook

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172 CHECKLISTS

CHECKLIST 5-20: Management Questionnaire

Medical Practice

Date: ____________________

Exact Practice Name: ____________________________________________________

Address: _______________________________________________________________

_____________________________________________________________

Phone: __________________________

Analyst/Interviewer: _____________________________________________________

The objective of this management interview is to provide us with operational infor-

mation that will aid us in the valuation of your practice. We will keep the informa-

tion conﬁdential. Describe the following to the best of your ability. on a separate

sheet of paper, with reference to each item number. If some items are not applica-

ble, please indicate N/A.

1. Interviews:

Name

Title

(a) _____________________________ _________________________________

(b) _____________________________ _________________________________

(d) _____________________________ _________________________________

2. Description of the Practice

(a) Full name of the practice

(b) Date the practice was established

physicians, important dates, past locations, etc.

3. Name, Address, and Telephone Number of the Practice’s Attorney(s).

4. Name, Address, and Telephone Number of the Practice’s Accountant(s).

5. Physicians

(a) For all doctors, provide

(1) Name

(2) Age

(3) Education background

(4) Special license requirements

(5) Board certiﬁcation

(6) Number of years experience

(7) Articles written

(8) Lectures delivered

(a) General health (excellent, good, or poor)

(b) Describe life insurance in which the practice is the beneﬁciary

(1) Average number of patients per day

(2) Nature of treatment

(3) Average time per patient/treatment

(4) Hours worked per day

(5) Time spent in

i. Office visits/treatments

ii. Surgery—hospital

iii. Surgery—in office

iv. Administration

v. Promotion

vi. Civic affairs

6. Personnel

(a) Provide a current organizational chart

(b) Provide a list of employees, other than physicians, at year-end for last year,

including current employee classiﬁcations, general wage scales, and approx-

imate rate (distinguish full-time and part-time)

pensation (including bonuses) for the current year and past two years

Name

Title LOS Age Compensation

(1) ______________ ________________ _____ _____ _______________

(2) ______________ ________________ _____ _____ _______________

(3) ______________ ________________ _____ _____ _______________

(4) ______________ ________________ _____ _____ _______________

(5) ______________ ________________ _____ _____ _______________

(d) List board of directors by name and title, including occupation for outside

members

7. The Practice

(a) Type of marketing

(1) Professional referral

(2) Patient referral

(3) Direct mail

(4) Yellow pages

(5) Other

(b) Provide list of competition

(1) Specialized

(2) General

(3) Minihospitals

Management Questionnaire Medical Practice 173

(1) Past

(2) Projected

(3) Limiting factors

(4) New products/services being considered

(5) Any recent sales of stock (or interests) or offers to buy (or sell)

(6) Any comparable sales of similar practices

8. Property and Equipment

(a) Describe your office facilities

(1) Square feet

(2) Number of examining rooms

(3) Number of operating rooms

(4) Number of x-ray rooms

(5) If owned, provide

i. Age and condition

ii. Assessed value

iii. Fair market value, if known

(6) If leased, provide

i. Amount of monthly payment

(b) Discuss specialized equipment

(1) If owned, provide

i. Age and condition

ii. Assessed value

iii. Fair market value, if known

(2) If leased, amount of monthly payment

(d) Describe the library

(1) Original cost

(2) Replacement cost

(3) Unique volumes

9. General Outlook (if not covered elsewhere)

10. Other Pertinent Information About the Practice

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

174 CHECKLISTS

CHECKLIST 5-21: Valuation Information Request

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, indicate

N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. Copyrights

_____ 1. List of all copyrighted registrations.

_____ 2. List of works (articles, books, painting, etc.).

_____ 3. Identify copyright names that are associated with products and/or

services (such as software or report templates).

_____ 4. Identify historical sale of products and/or services employing the

works for the last ﬁve years.

_____ 5. Projection of products and/or services that will employ the works for

the next ﬁve years.

_____ 6. Details of licensing transaction(s) (in or out) of any copyrighted

works.

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

Valuation Information Request Copyright 175

CHECKLIST 5-22: Valuation Information Request

Customer Relationships

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, please indi-

cate N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. Customer Relationships

_____ 1. Customer sales history for the last ﬁve years for the top 10 customers.

_____ 2. Complete customer history for the last ﬁve years (this would be for

liﬁng).

_____ 3. Financial data representing annual costs for the last ﬁve years

associated with developing/soliciting new customers.

_____ 4. Schedule of new customers gained in each of the last ﬁve years with

sales.

_____ 5. For the last ﬁve years, number of customers in a given year that failed

to purchase in the following year, including those customers’ sales for

the prior year.

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

176 CHECKLISTS

CHECKLIST 5-23: Valuation Information Request

In-Process Research and

Development

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, indicate

N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. In-Process Research and Development

_____ 1. Description of the in-process research and development.

_____ 2. Description of competitive advantages and disadvantages of the in-

process research and development.

_____ 3. Description of industry trends and competitive pressures that may

affect the useful life of the in-process research and development.

_____ 4. In light of 2 and 3 above, estimate the useful life of the in-process

research and development support.

_____ 5. Cost records documenting development of the in-process research and

development, including:

(a) Person hours to develop;

(b) Various technical levels of persons working on the assignment;

(d) Information to determine overhead rate.

_____ 6. In the absence of cost records, estimate effort to create the in-process

research and development, including:

(a) Who would work on the assignment (employees and consultants);

(b) Pay rates for individuals in 6a; and

_____ 7. Projection of products and/or services that will employ the in-process

research and development for the next ﬁve years:

(a) Projection of revenues including licensing income for the life span

of the in-process research and development;

(b) Projection of direct expenses associated with producing revenue in

7a; and

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

Valuation Information Request In-Process Research and Development 177

CHECKLIST 5-24: Valuation Information Request

Know-How

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, please indi-

cate N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. Know-How

_____ 1. Description of know-how, including competitive advantages and

disadvantages.

_____ 2. Description of industry trends and competitive pressures that may

affect the useful life of the know-how.

_____ 3. In light of 1 and 2 above, estimate the useful life of the know-how.

_____ 4. Products or services that employ the know-how.

_____ 5. Historical cost records documenting development of the know-how,

including:

(a) Person hours to develop;

(b) Various technical levels of persons working on the assignment;

(d) Information to determine overhead rate.

_____ 6. In the absence of historical cost records, estimate corporate effort to

re-create the know-how if it were to be developed from scratch,

including:

(a) Who would work on the assignment (employees and consultants);

(b) Pay rates for individuals in 6a; and

_____ 7. Historical sale of products and/or services employing the know-how

for the last ﬁve years.

_____ 8. Know-how associated with products and/or services:

(a) Projection of products and/or services that will employ the know-

how for the next ﬁve years;

(b) Projection of direct expenses associated with producing revenue in

8a; and

_____ 9. Details of licensing transaction(s) (in or out) of any know-how.

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

178 CHECKLISTS

CHECKLIST 5-25: Valuation Information Request

Patent

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, indicate

N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. Patent

_____ 1. Summary of patents held by the company.

_____ 2. Copies of patent applications and patent abstracts.

_____ 3. Distinguish which patents have commercial applications (i.e., are

producing or are reasonably forecast to produce revenue in the future).

_____ 4. Historical cost records documenting development of the patent(s):

(a) Person hours to develop;

(b) Various technical levels of people working on the assignment;

(d) Information to determine overhead rate.

_____ 5. Identify patents and associated products that now have or are

expected to have commercial viability:

(a) Projection of revenues related to patent over the life of the patent;

and

(b) Projection of direct expenses associated with producing revenue in 5a.

_____ 6. Comment on the possibility of extending patent protection beyond

statutory life of patent.

_____ 7. Details of licensing transaction(s) (in or out) of any patents.

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

Valuation Information Request Patent 179

180 CHECKLISTS

CHECKLIST 5-26: Valuation Information Request

Software

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, please indi-

cate N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. Software

_____ 1. Describe the function of the software.

_____ 2. For Cost Approach:

(a) If available, provide historical cost records documenting develop-

ment of the software, including:

(1) Person hours to develop;

(2) Various technical levels of people working on the assignment;

(3) Pay scales for individuals in 2a(2); and

(4) Information to determine overhead rate.

(b) In the absence of historical cost records, estimate effort to re-create

the software if it were to be developed from scratch, including:

(1) Who would work on the assignment (employees and

consultants);

(2) Pay rates for individuals in 2b(1); and

(3) Information to determine overhead rate.

_____ 3. Liﬁng/Obsolescence:

(a) Expected useful life at inception and at valuation date (obtain sup-

port for estimate);

(b) Date software was actually placed in use;

(d) Description of internal development of replacement software that

might shorten life; and

(e) Description of external factors that may affect life.

_____ 4. For Income Approach:

(a) Obtain historical revenues applicable to software;

(b) Projection of revenues including licensing income for life span of

software;

(d) Obtain or develop indirect expenses (i.e., overhead); and

(e) Identify expenses, direct and indirect, not associated with acquired

software.

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.

Valuation Information Request Proprietary Processes/Products Technology 181

CHECKLIST 5-27: Valuation Information Request

Proprietary Processes/Products

Technology

Business Name: ________________________________________________________

Valuation Date: ________________________________________________________

This is a generalized information request. Some items may not pertain to your com-

pany, and some items may not be readily available to you. In such cases, please indi-

cate N/A or notify us if other arrangements can be made to obtain the data. Items

already provided have been marked with an “X”. If you have any questions on the

development of this information, please call.

A. Proprietary Processes/Products Technology

_____ 1. Description of the proprietary process/product technology.

_____ 2. Description of competitive advantages and disadvantages of the

proprietary process/product technology.

_____ 3. Description of industry trends and competitive pressures that may

affect the useful life of the proprietary process/product technology.

_____ 4. In light of 2 and 3 above, estimate the useful life of the proprietary

process/product technology support.

_____ 5. Historical cost records documenting development of the

process/product technology:

(a) Person hours to develop;

(b) Various technical levels of people working on the assignment;

(d) Information to determine overhead rate.

_____ 6. In the absence of historical cost records, estimate effort to recreate the

process/product technology if it were to be developed from scratch:

(a) Who would work on the assignment (employees and consultants);

(b) Pay rates for individuals in 6a; and

_____ 7. Historical sale of products and/or services employing process/product

technology for the last ﬁve years.

_____ 8. Projection of products and/or services that employ the process/product

technology for the next ﬁve years:

(a) Projection of revenues including licensing income for the life span

of process/product technology;

(b) Projection of direct expenses associated with producing revenue in

8a; and

_____ 9. Details of licensing transaction(s) (in or out) of any technology.

Disclaimer Excluding Any Warranties: This checklist is designed to provide guidance to analysts, auditors, and man-

agement, but is not to be used as a substitute for professional judgment. These procedures must be altered to ﬁt each

assignment. The practitioner takes sole responsibility for implementation of this guide. The implied warranties of mer-

chantability and ﬁtness of purpose and all other warranties, whether expressed or implied, are excluded from this trans-

action and shall not apply to this guide. The Financial Valuation Group shall not be liable for any indirect, special, or

consequential damages.