Get NY CHAR004 2012

B eginning fund balance O ther changes in fund balance xiii. E nding fund balance lines x thru xii M ail completed form with required fee and attachm ents to the address at the top of this page Page 1 of 1 Form CHAR004 2012. Form Annual Filing for Charitable Lead Trusts CHAR004 New York State Department of Law Office of the Attorney General Charities Bureau - Registration Section 120 Broadway New York NY 10271 www. charitiesnys. com Estates Powers Trusts Law Open to Public Inspection Part A - General Information / 2 0 12 and ending mm/dd/yyyy 1. For the period beginning mm/dd/yyyy 2. Check if applicable for NYS G 3. N am e of charitable lead trust 5. Fed* em ployer ID no. E IN - Address change 6. N Y S tate registration no. - - Name change Initial filing Final filing 4. N um ber and street or P. O. box if m ail not delivered to street address R oom /suite 7. T elephone num ber Amended filing C ity or tow n state or country and zip 4 NY registration pending 8. E m ail address Part B - Certification - Signature Required I certify under penalties of perjury that I reviewed this report including all attachments and to the best of our knowledge and belief they are true correct and complete in accordance with the laws of the State of New York applicable to this report. Authorized Representative S ignature P rinted N am e T itle D ate Part C - Fee Submitted Indicate the EPTL filing fee you are submitting along with this form Total amount distributed to charity is less than 50 000. 25 G. Submit only one check or money order for the total fee payable to NYS Department of Law 1500 G Part D - Attachments - All Documents Required Attach a copy of the trust s IRS Form 5227 Split Interest Trust Information Return Part E - Financial Report a* C H AR G E S D IS TR IB U TIO N TO C H AR ITY to line vii i. P rincipal received ii. Incom e collected B eneficiary A m ount R ealized increases iv* T otal charges lines i thru iv b. C R E D ITS v* Total D istributions to C harity vi. A dm inistrative expenses D istributions to charity viii. ix. T otal credits lines v thru viii c* FU N D B ALAN C E x. Increase or decrease for the year subtract line ix from line iv xi. charitiesnys. com Estates Powers Trusts Law Open to Public Inspection Part A - General Information / 2 0 12 and ending mm/dd/yyyy 1. For the period beginning mm/dd/yyyy 2. Check if applicable for NYS G 3. N am e of charitable lead trust 5. For the period beginning mm/dd/yyyy 2. Check if applicable for NYS G 3. N am e of charitable lead trust 5. Fed* em ployer ID no. E IN - Address change 6. N Y S tate registration no. - - Name change Initial filing Final filing 4. Fed* em ployer ID no. E IN - Address change 6. N Y S tate registration no. - - Name change Initial filing Final filing 4. N um ber and street or P. O. box if m ail not delivered to street address R oom /suite 7. T elephone num ber Amended filing C ity or tow n state or country and zip 4 NY registration pending 8. N um ber and street or P. O. box if m ail not delivered to street address R oom /suite 7. T elephone num ber Amended filing C ity or tow n state or country and zip 4 NY registration pending 8. E m ail address Part B - Certification - Signature Required I certify under penalties of perjury that I reviewed this report including all attachments and to the best of our knowledge and belief they are true correct and complete in accordance with the laws of the State of New York applicable to this report. .