Form Ct-12s - Tax Return For Split-Interest Trusts - 2004
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1
2Form
Charitable Activities Section
For Accounting Periods Beginning in:
CT-12S
2004
Oregon Department of Justice
1515 SW 5th Avenue, Suite 410
VOICE (503) 229-5725
Portland, OR 97201-5451
TTY
(503) 378-5938
For Split-Interest Trusts
E-Mail: charitable.activities@doj.state.or.us
FAX
(503) 229-5120
Web site:
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
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 and any schedules presented as supplementary information to the basic financial statements.
3.
Has the trust or any officer, trustee, or executive personnel of the trust ever been involved in a voluntary agreement with any
district attorney or attorney general or a legal action in any court regarding the trust’s solicitation, administration, or management
Yes
No
practices? If yes, attach copies of the agreement and a written explanation.
4.
During this reporting period, did the trust amend any trust documents OR did the trust receive a determination letter from the
Internal Revenue Service indicating a new or amended tax-exempt status? If yes, attach a copy of the amended document or
Yes
No
letter.
Yes
No
5.
Is the trust ceasing operations and is this the final report?
(If yes, see instructions.)
6.
Provide contact information for the person responsible for retaining the trust’s records.
Name
Position
Phone
Mailing 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 any compensation from the organization. Attach additional sheets if necessary. If an IRS form is attached that includes substantially the
same information, the phrase “See IRS Form” may be entered in lieu of completing this section.
(A) Name, daytime phone number
(B) Title &
(C)
(D) Contributions
(E) Expense
& mailing address
average weekly
Compensation
to benefit plans
account & other
hours devoted to
(If not paid,
& deferred
allowances
position
enter $0)
compensation
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(
)
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(
)
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(
)
Form Continued on Reverse Side
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