Form CHAR004
Annual Filing for Charitable Lead Trusts
New York State Department of Law (Office of the Attorney General)
Charities Bureau - Registration Section
28 Liberty Street
New York, NY 10005
www.charitiesnys.com
2 0 15
Estates, Powers & Trusts Law
Open to Public
Inspection
Part A - General Information
1. For the period beginning (mm/dd/yyyy)
/ 2 015 and ending (mm/dd/yyyy)
2. Check if applicable for NYS:
G Address change
G Name change
G Initial filing
G Final filing
G Amended filing
G NY registration pending
3. Nam e of charitable lead trust 5. Fed. em ployer ID no. (EIN ) (##-#######)
6. NY State registration no. (##-##-##)
4. Number and street (or P.O. box if mail not delivered to street address) Room/suite 7. Telephone number
City or town, state or country and zip + 4 8. Email 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.
Signature Printed Name Title Date
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
Total amount distributed to charity is $50,000 or more, but less than $250,000 . . . . . . . . . $50 G
Total amount distributed to charity is $250,000 or more, but less than $1,000,000 ......... $100 G
Total amount distributed to charity is $1,000,000 or more, but less than $10,000,000 ...... $250 G
Total amount distributed to charity is $10,000,000 or more, but less than $50,000,000 .... $750 G
Total amount distributed to charity is $50,000,000 or more ................................$1500 G
Submit only one check or money order for the
total fee, payable to “NYS Department of Law”
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. CHARGES DISTRIBUTION TO CHARITY (to line vii)
i. Principal received $ Beneficiary Amount
ii. Income collected $ $
iii. Realized increases $ $
iv. Total charges (lines i thru iv) $$
$
b. CREDITS
$
v. Realized decreases $ Total Distributions to Charity $
vi. Administrative expenses $
vii. Distributions to charity $
viii. Distributions to others $ DISTRIBUTION TO OTHERS (to line viii)
ix. Total credits (lines v thru viii) $ Beneficiary Amount
$
c. FUND BALANCE
$
x. Increase (or decrease) for the year
(subtract line ix from line iv)
$
$
xi. Beginning fund balance $ $
xii. Other changes in fund balance $ $
xiii. Ending fund balance (lines x thru xii) $ Total Distributions to Others $
– Mail completed form with required fee and attachments to the address at the top of this page –
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Form CHAR004 (2015)
Authorized Representative
