Form Ct-12s - Tax Return For Split-Interest Trusts - 2016

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Form
Charitable Activities Section
For Accounting Periods Beginning in:
CT-12S
Oregon Department of Justice
2016
100 SW Market Street
VOICE
(971) 673-1880
Portland, OR 97201-5702
TTY
(800) 735-2900
For Split-Interest Trusts
Email: charitable.activities@doj.state.or.us
FAX
(971) 673-1882
Website:
Section I.
General Information
1.
Cross Through Incorrect Items and Correct Here:
(See instructions for change of name or accounting period.)
Registration #:
Organization Name:
Address:
City, State, Zip:
Phone:
Fax:
Amended
Email:
Report?
Period Beginning:
/
/
Period Ending:
/
/
2.
Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor’s report, financial statements,
Yes
No
accompanying notes, schedules, or other documents supplementing the report or financial statements.
3.
Has the trust or any of its officers, directors, trustees, or key employees ever signed a voluntary agreement with any
government agency, such as a state attorney general, secretary of state, or local district attorney, or been a party to legal action
Yes
No
in any court or administrative agency regarding charitable solicitation, administration, management, or fiduciary practices? If
yes, attach explanation of each such agreement or action. See instructions.
4.
During this reporting period, did the trust amend any trust documents OR did the trust receive a determination letter from the
Yes
No
Internal Revenue Service relating to its tax-exempt status? If yes, attach a copy of the amended document or letter.
Yes
No
5.
Is the trust ceasing operations and is this the final report? (If yes, see instructions on how to close your registration.)
6.
Provide contact information for the person responsible for retaining the trust’s records.
Name
Position
Phone
Mailing Address & Email Address
7.
List of Officers, Directors, Trustees and Key Employees – List each person who held one of these positions at any time during the year even if they did
not receive compensation. Attach additional sheets if necessary. If an attached IRS form includes substantially the same compensation information,
the phrase “See IRS Form” may be entered in lieu of completing that section.
(A) Name, mailing address, daytime phone number
(B) Title &
(C)
and email address
average weekly
Compensation
hours devoted to
(enter $0 if
position
position unpaid)
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
Phone:
(_ _ _)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email:
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
Phone:
(_ _ _)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email:
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(_ _ _)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email:
Form Continued on Reverse Side

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