Charities Form 004 - Annual Report Of Charitable Trust Page 2

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Charities Form 004
Page 2 of 5
19. Total charges (lines 13 thru 18)
______
_____
_____
_____
LIABILITIES
20. Mortgages payable
6
______
_____
_____
_____
21. Other payable
6
______
_____
_____
_____
22. Total liabilities (lines 20 and 21)
______
_____
_____
_____
FUND BALANCES
23. Ending fund balances (lines 19 less 22)
______
_____
_____
_____
FEE PAID WITH THIS REPORT : $_____________________
(Based on ending fund balances at market value)
SCHEDULE A - ADMINISTRATION EXPENSES
Paid From
Principal
Income
Total
Trustees commissions
______ _____
_____
Advisory and custodial charges
______ _____
_____
Legal
______ _____
_____
Accounting
______ _____
_____
Income Taxes
______ _____
_____
Other (attach schedule)
______ _____
_____
TOTALS (to page 1 line 6)
______ _____
_____
SCHEDULE B - DISTRIBUTION TO BENEFICIARIES
Paid To
Beneficiary
If paid in kind - Describe
Charities
Others
1.
____________________________
_____
_____
_________________
2.
____________________________
_____
_____
_________________
3.
____________________________
_____
_____
_________________
4.
____________________________
_____
_____
_________________
5.
____________________________
_____
_____
_________________
TOTAL CHARITABLE DISTRIBUTION (to page 1 line 7)
_____
_____
TOTAL DISTRIBUTIONS TO OTHERS (to page 1 line 8)
_____
I (We) swear under oath that this report (including any accompanying schedules, and statements) has (have) been examined by
me (us) and to the best of my (our) knowledge and belief is a true, correct, and complete report.
STATE OF NEW YORK )
) SS:
COUNTY OF
)
Sworn to before me this
day of
, 19
3/3/00

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