1041-A
U.S. Information Return
Form
Trust Accumulation of Charitable Amounts
OMB No. 1545-0094
(Rev. February 2012)
Department of the Treasury
For calendar year 20
Internal Revenue Service
Name of trust
Employer identification number
Name of trustee
Number, street, and room or suite no. (or P.O. box)
City or town, state, and ZIP code
Part I
Income and Deductions (See the instructions for Form 1041 or Form 5227.) If total income is $25,000 or
less, skip lines 1–8 and enter total income on line 9.
1
1
Interest income .
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2
2
Dividends .
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3
Business income or (loss) (attach Schedule C or C-EZ (Form 1040)) .
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3
4
Capital gain or (loss) (attach Schedule D (Form 1041))
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4
5
5
Rents, royalties, partnerships, other estates and trusts, etc. (attach Schedule E (Form 1040))
6
Farm income or (loss) (attach Schedule F (Form 1040)) .
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6
7
Ordinary gain or (loss) (attach Form 4797)
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7
8
8
Other income (state type of income)
Total income (combine lines 1 through 8) .
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9
9
10
Interest .
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10
11
11
Taxes
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12
12
Charitable deduction (itemize by charitable purpose; include payee’s name and address)
13
Trustee fees .
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13
14
Attorney, accountant, and return preparer fees .
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14
Other deductions (attach schedule)
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15
15
Distributions of Income Set Aside for Charitable Purposes (see instructions)
Part II
16
Accumulated income set aside in prior tax years for which a deduction was claimed under section
642(c) .
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16
Income set aside in prior tax years for which a deduction was claimed under section 642(c)
17
and which was distributed during the current tax year (itemize by charitable purpose; include
payee’s name and address) .
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a
17a
b
17b
c
17c
d
17d
e
17e
18
18
Total (add lines 17a through 17e) .
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19
Balance (subtract line 18 from line 16)
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19
20
Income set aside during the current tax year for which a deduction was claimed under section
642(c) (included in Part I, line 12) .
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20
Carryover (add lines 19 and 20)
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21
21
Distributions of Principal for Charitable Purposes (see instructions)
Part III
22
22
Principal distributed in prior tax years for charitable purposes
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23
Principal distributed during the current tax year for charitable purposes (itemize by charitable
purpose; include payee’s name and address) .
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a
23a
b
23b
c
23c
d
23d
e
23e
Total (add lines 23a through 23e)
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24
24
1041-A
Form
(Rev. 2-2012)
For Paperwork Reduction Act Notice, see the instructions.
Cat. No. 10615B