Form 5227 Split-Interest Trust Information Return

OMB No. 1545-0196

Department of the Treasury

Internal Revenue Service © See separate instructions.

Full name of trust Employer identification number

Name of trustee Type of Entity:

Charitable lead trust Number, street, and room or suite no. (If a P.O. box, see instructions)

Charitable remainder annuity trust

described in section 664(d)(1)

City, state, and ZIP code

Charitable remainder unitrust

described in section 664(d)(2)

Pooled income fund described in

section 642(c)(5)

Fair market value (FMV) of assets at end of tax year Date the trust was created

Other

Yes No

Ordinary Income (Section 664 trust only)

1 Interest income 1

2 Dividends 2

3 Business income or (loss) (attach Schedule C or C-EZ (Form 1040)) 3

4 Rents, royalties, partnerships, other estates and trusts, etc. (attach Schedule E (Form 1040)) 4

5 Farm income or (loss) (attach Schedule F (Form 1040)) 5

6 Ordinary gain or (loss) (attach Form 4797) 6

7 Other income (state nature of income) 7

8 Total ordinary income (combine lines 1 through 7) 8

Deductions Allocable to Ordinary Income

9 Interest 9

10 Taxes 10

11 Other deductions (attach a separate sheet listing deductions) 11

12 Total deductions (add lines 9 through 11) 12

13 Ordinary income less deductions (subtract line 12 from line 8). Enter here and on line 21, column (a) 13

Capital Gains (Losses) and Allocable Deductions

14

Total short-term capital gain (loss) for tax year (attach Schedule D

(Form 1041))

14

15 Deductions allocable to short-term capital gains 15

16 Balance (subtract line 15 from line 14). Enter here and on line 21, column (b) 16

17

Total long-term capital gain (loss) for tax year (attach Schedule D

(Form1041))

17

18 Deductions allocable to long-term capital gains 18

19 Balance (subtract line 18 from line 17). Enter here and on line 21, column (c) 19

Accumulation Schedule (Section 664 trust only)

Capital gains and (losses) (d) Nontaxable

income

(a) Ordinary

income Accumulations

(b) Net short-term (c) Net long-term

20 Undistributed from prior tax years

21 Current tax year (before distributions)

22 Total (add lines 20 and 21)

23 Undistributed at end of tax year

Current Distributions Schedule (Section 664 trust only)

Capital gains (d) Nontaxable

income

(a) Ordinary

income

Identifying

number Name of recipient (e) Corpus (b) Short-term (c) Long-term

24

25

26

Did the split-interest trust have any unrelated business taxable income (section 664 trusts

only)? If “Yes,” file Form 1041

For Paperwork Reduction Act Notice, see page 1 of the instructions. Cat. No. 13227T Form 5227 (1994)

C D

A

B

F

E Check

applicable

boxes:

Initial return

Change in Trustee’s ©

Part III

Part I

Part II

(1)

(2)

(3)

(4)

(5)

Final return Amended return

Name Address
Form 5227 (1994) Page 2

Balance Sheet (see instructions)

(c) FMV (see

instructions) Assets

27 Cash — non-interest bearing 27

28 Savings and temporary cash investments 28

29a Accounts receivable 29a

b Less: allowance for doubtful accounts 29b

30

Receivables due from officers, directors, trustees, and other

disqualified persons (attach schedule)

30

31a Other notes and loans receivable 31a

32 Inventories for sale or use 32

33 Prepaid expenses and deferred charges 33

34a Investments — U.S. and state government obligations 34a

36 Investments — other (attach schedule) 36

35a

Investments — land, buildings, and equipment:

basis

35a

b Less: accumulated depreciation 35b

37a Land, buildings, and equipment: basis 37a

b Less: accumulated depreciation 37b

38 Other assets (describe © ) 38

39 Total assets (add lines 27 through 38) (must equal line 49) 39

Liabilities

40 Accounts payable and accrued expenses 40

42

41 Revenue designated for future periods

43

42 Loans from officers, directors, trustees, and other disqualified persons

44

43 Mortgages and other notes payable (attach schedule)

45

44 Other liabilities (describe © )

46

45

47a

Total liabilities (add lines 40 through 44)

Net Assets

48

46 Trust principal or corpus

49

47a Undistributed income

b Undistributed capital gains

c Undistributed nontaxable income

48 Total net assets (add lines 46 through 47c)

49 Total liabilities and net assets (add lines 45 and 48)

(a) Beginning-ofYear Book Value

b Less: allowance for doubtful accounts

Investments — corporate stock (attach schedule)

Investments — corporate bonds (attach schedule)

b

c

47b

47c

41

31b

34b

34c

(b) End-of-Year

Book Value

Part IV

Part V-A Charitable Remainder Annuity Trust Information

Part V-B Charitable Remainder Unitrust Information

To be completed ONLY by a section 664 charitable remainder annuity trust:

50a Enter the initial fair market value (FMV) of the property placed in the trust

Enter the total annual annuity amounts for all recipients (attach schedule showing the amount for each

recipient if more than one)

b

50a

50b

To be completed ONLY by a section 664 charitable remainder unitrust:

51a Enter the unitrust fixed percentage to be paid to the recipients 51a

b Subtract line 45, column (c), from line 39, column (c), and multiply the result by the percentage on line 51a 51b

52a Trust’s accounting income for 1994

53a Total accrued distribution deficiencies from previous years (see instructions)

Unitrust amount. If there is more than one recipient, attach a schedule showing the percentage of

the total unitrust dollar amount payable to each recipient

54

55 Carryover of distribution deficiency (subtract line 54 from line 53b) 55

%

Note: Complete lines 52a through 53b ONLY for those unitrusts whose governing instruments provide for determining

required distributions with reference to the unitrust’s income. Otherwise, enter the amount from line 51b on line 54.

b Enter the smaller of line 51b or line 52a here, and on line 54 below, unless the following “Caution” applies

52a

52b

Caution: Lines 53a and b need to be completed by those unitrusts whose governing instruments provide for current

distributions to make up for any distribution deficiencies in previous years due to the trust income limit. See Regulations

section 1.664-3(a)(1)(b)(2). For these trusts, when completing line 54 enter the smaller of line 52a or line 53b.

b Add lines 51b and 53a

54

53a

53b
Form 5227 (1994) Page 3

Statements Regarding Activities (see instructions)

File Form 4720 if you answer “No” to question 2b or 6b, or if you answer “Yes” to question 2c, 4b, Yes No

5a, or 5b, unless an exception applies.

1 At the time of filing this return, does the trust satisfy the requirements of section 508(e) either:

● By the language in the governing instrument; or

● By state legislation that effectively amends the governing instrument so that no mandatory directions

that conflict with the state law remain in the governing instrument? 1

2 Taxes on self-dealing (section 4941):

a During 1994 did the trust (either directly or indirectly):

2a(1) (1) Engage in the sale or exchange, or leasing of property with a disqualified person?

2a(2) (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a disqualified person?

2a(3) (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?

2a(4) (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?

(5) Transfer any income or assets to a disqualified person (or make any of either available for the benefit

or use of a disqualified person)? 2a(5)

(6) Agree to pay money or property to a government official? (Exception: Check “No” if the trust agreed

to make a grant to or to employ the official for a period after he or she terminates government service, if

he or she is terminating within 90 days.) 2a(6)

If you answered “Yes” to any of the questions 2a (1) through (6), were the acts engaged in excepted acts

as described in Regulations sections 53.4941(d)-3 and 4?

b

2b

Did the trust engage in a prior year in any of the acts described in 2a, other than excepted acts, that were

not corrected before January 1, 1994?

c

2c

3a Do the provisions of section 4947(b)(3)(A) apply? (see instructions) (If “Yes,” enter “N/A” in questions 4 and 5.) 3a

b Do the provisions of section 4947(b)(3)(B) apply? (see instructions) (If “Yes,” enter “N/A” in questions 4 and 5.) 3b

4 Taxes on excess business holdings (section 4943):

4a

Did the trust hold more than a 2% direct or indirect interest in any business enterprise at any time during

1994?

a

b If “Yes,” did the trust have excess business holdings in 1994 as a result of (1) any purchase by the trust

or disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved

by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3)

the lapse of the 10-, 15-, or 20-year first phase holding period? 4b

(Use Schedule C, Form 4720 to determine if the trust had excess business holdings in 1994. )

5 Taxes on investments that jeopardize charitable purposes (section 4944):

a Did the trust invest during 1994 any amount in a manner that would jeopardize its charitable purpose? 5a

Did the trust make any investment in a prior year (but after December 31, 1969) that could jeopardize its

charitable purpose that had not been removed from jeopardy before January 1, 1994?

b

5b

6 Taxes on taxable expenditures (section 4945):

a During 1994 did the trust pay or incur any amount to:

6a(1) (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?

6a(2) (2) Influence the outcome of any specific public election (see section 4955); or to carry on, directly or

indirectly, any voter registration drive?

6a(3) (3) Provide a grant to an individual for travel, study, or other similar purposes?

(4) Provide a grant to an organization other than a charitable, etc., organization described in sections

509(a)(1), (2), or (3), or section 4940(d)(2)? 6a(4)

(5) Provide for any purpose other than religious, charitable, scientific, literary, or educational purposes, or

for the prevention of cruelty to children or animals? 6a(5)

If you answered “Yes” to any of the questions 6a(1) through 6a(5), were all such transactions excepted

transactions as described in Regulations section 53.4945?

b

6b

If you answered “Yes” to question 6a(4), does the trust claim exemption from the tax because it maintained

expenditure responsibility for the grant? (see instructions)

c

6c

If “Yes,” attach the statement required by Regulations section 53.4945-5(d).

7

Are you using this return only to report the income and assets of a segregated amount under section

4947(a)(2)(B)?

7

Part VI

56 Did the trustee change the method of determining the fair market value of the assets? Yes No

If “Yes,” attach an explanation.

57 Were any additional contributions received by the trust during 1994? Yes No

If “Yes,” attach a schedule that lists the assets, and the date(s) received.
Form 5227 (1994) Page 4

Questionnaire for Charitable Lead Trusts and Pooled Income Funds

Section A.—Charitable Lead Trusts

1 Does the governing instrument require income in excess of the required annuity or unitrust payments to be

paid for charitable purposes? Yes No

2 Enter the amount of any excess income required to be paid for charitable purposes for 1994 2

3

Enter the amount of annuity or unitrust payments required to be paid to charitable beneficiaries

for 1994

3

4

Enter the amount of annuity or unitrust payments required to be paid to private beneficiaries for

1994

4

Section B.—Pooled Income Funds

1 Enter the amount of contributions received during 1994 1

2 Enter the amount required to be distributed for 1994 to satisfy the remainder interest 2

Enter any amounts that were required to be distributed to the remainder beneficiary that remain

undistributed

3

3

4 Enter the amount of income required to be paid to private beneficiaries for 1994 4

5 Enter the amount of income required to be paid to the charitable remainder beneficiary for 1994 5

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than trustee) is based on all information of which preparer Please has any knowledge.

Sign

Here

Signature of trustee or officer representing trustee Date

Check if selfemployed

Date Preparer’s social security no. Preparer’s

signature

Paid

Preparer’s

Use Only

Firm’s name (or yours,

if self-employed)

and address

E.I. No.

ZIP code

Part VII

©

©

©

©

Check this box if you are filing for a charitable remainder annuity trust or a charitable remainder unitrust whose charitable

interests involve only cemeteries or war veterans’ posts ©

Check this box if any of the split-interest trust’s income interests expired during 1994 ©

Other Information (All split-interest trusts must check either of these boxes if applicable.)