Form 2g - Grantor'S/owner'S Share Of A Grantor-Type Trust - 2012

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File pg. 1
FOR PRIVACY ACT NOTICE,
PRINT IN BLACK INK
SEE INSTRUCTIONS.
Calendar year filers enter 01-01-2012 and 12-31-2012 below. Fiscal year filers enter appropriate dates.
Tax year beginning 3
Tax year ending 3
Form 2G
Grantor’s/Owner’s Share of a Grantor-Type Trust
2012
GRANTOR’S/OWNER’S IDENTIFICATION NUMBER
NAME OF GRANTOR/BENEFICIARY
LEGAL DOMICILE
MAILING ADDRESS OF GRANTOR/BENEFICIARY
CITY/TOWN/POST OFFICE
STATE
ZIP + 4
ENTITY’S IDENTIFICATION NUMBER
NAME OF FIDUCIARY
TITLE OF FIDUCIARY
NAME OF ENTITY
C/O
MAILING ADDRESS OF FIDUCIARY
CITY/TOWN/POST OFFICE
STATE
ZIP + 4
Fill in all that apply:
Grantor-type trust
Pooled income fund
Charitable remainder annuity trust
3
3
3
Amended
Charitable remainder unitrust
3
3
Other
If showing a loss, mark an X in box at left
5
0 0
1
Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1
0 0
2
Interest from corporate bonds or notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2
0 0
3
Non-Massachusetts state and municipal bond interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3
0 0
4
Other interest income (including Massachusetts bank interest; see line 15). . . . . . . . . . . . . . . . . . . . 3 4
0 0
5
Interest from U.S. obligations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5
0 0
6
Short-term capital gains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6
0 0
7
Short-term capital losses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 7
8
Gain on the sale, exchange or involuntary conversion of property used in a trade or business and
0 0
held for one year or less. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 8
9
Loss on the sale, exchange or involuntary conversion of property used in a trade or business
0 0
and held for one year or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9
0 0
10
Long-term capital gains or losses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 10
SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.
Signature of fiduciary
Date
Print paid preparer’s name
Preparer’s SSN
or PTIN
3
/
/
Title
Date
Paid preparer’s phone
Paid preparer’s
(
)
EIN
3
/
/
May DOR discuss this return with the preparer?
Yes
Paid preparer’s signature
Date
Fill in if self-employed
3
3
/
/
Mail to: Massachusetts Department of Revenue, PO Box 7017, Boston, MA 02204.

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