Form 5227 Split-Interest Trust Information Return

O

Department of the Treasury

Internal Revenue Service  See separate instructions.

Full name of trust Employer identificatio

Name of trustee Type of Entity

Charitable lea

Number, street, and room or suite no. (If a P.O. box, see page 3 of the instructions.)

Charitable re

described in 

City, state, and ZIP code

Charitable re

described in 

Pooled incom

section 642(c

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

2a Qualified dividends (see instructions) 2a

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, 2b, and 3 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 or (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

17a

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

(Form 1041))

17a

18 Deductions allocable to long-term capital gains 18

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

Accumulation Schedule (Section 664 trust only)

Capital gains and (losses) 

(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) Nonta

incom

(a) Ordinary

income

Identifying

number Name of recipient 

(b) Short-term (c) Long-term

24a

b

c

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 10 of the instructions. Cat. No. 13227T 

C D

A

B

F

E Check applicable

boxes (see

instructions)

Initial return

Change in trustee’s 

Part III

Part I

Part II

(1)

(2)

(3)

(4)

(5)

Final return Amended return

Name Address

28% rate gain or (loss)

Unrecaptured section 1250 gain

b

c

17b

17c

b Ordinary dividends (including qualified dividends) 2b
Form 5227 (2004) 

Balance Sheet (see page 6 of the instructions)

Assets

25 Cash — non-interest-bearing 25

26 Savings and temporary cash investments 26

27a Accounts receivable 27a

b Less: allowance for doubtful accounts 27b

28

Receivables due from officers, directors, trustees, and other

disqualified persons (attach schedule)

28

29a Other notes and loans receivable 29a

30 Inventories for sale or use 30

31 Prepaid expenses and deferred charges 31

32a Investments — U.S. and state government obligations (attach schedule) 32a

34 Investments — other (attach schedule) 34

33a

Investments — land, buildings, and equipment:

basis (attach schedule)

33a

b Less: accumulated depreciation 33b

35a Land, buildings, and equipment: basis 35a

b Less: accumulated depreciation 35b

36 Other assets (describe  ) 36

37 Total assets (add lines 25 through 36) (must equal line 47) 37

Liabilities

38 Accounts payable and accrued expenses 38

40

39 Deferred revenue

41

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

42

41 Mortgages and other notes payable (attach schedule)

43

42 Other liabilities (describe  )

44

43

45a

Total liabilities (add lines 38 through 42)

Net Assets

46

44 Trust principal or corpus

47

45a Undistributed income

b Undistributed capital gains

c Undistributed nontaxable income

46 Total net assets (add lines 44 through 45c)

47 Total liabilities and net assets (add lines 43 and 46)

(a) Beginning-ofYear Book Value

b Less: allowance for doubtful accounts

Investments — corporate stock (attach schedule)

Investments — corporate bonds (attach schedule)

b

c

45b

45c

39

29b

32b

32c

(b) End-of-Yea

Book Value

Part IV

Charitable Remainder Annuity Trust Information (to be completed only by a section 

remainder annuity trust)

Part V-A

Part V-B Charitable Remainder Unitrust Information (to be completed only by a section 664 c

remainder unitrust)

48a 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

48

48

49a Enter the unitrust fixed percentage to be paid to the recipients 49

Unitrust amount. Subtract line 43, column (c), from line 37, column (c), and multiply the result by the

percentage on line 49a

b

49

50a Trust’s accounting income for 2004

Note: Complete lines 50a through 51b 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 49b on line 52.

b Enter the smaller of line 49b or line 50a here, and on line 52 on page 3, unless the Caution below applies

50

50

Caution: Lines 51a 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)(i)(b)(2). For these trusts, when completing

line 52 enter the smaller of line 50a or line 51b.

If there is more than one recipient, attach a schedule showing the percentage of the total unitrust

dollar amount payable to each recipient.
Form 5227 (2004) 

Statements Regarding Activities (see page 8 of the instructions)

1 Are the requirements of section 508(e) satisfied 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 Self-dealing (section 4941):

a During 2004, did the trust (either directly or indirectly):

(1)

(2)

(3)

(4)

(5)

(6)

If any answer is “Yes” to 1a(1)—(6), did any of the acts fail to qualify under the exceptions described in

Regulations sections 53.4941(d)-3 and 4, or in a current Notice regarding disaster assistance (see page 9

of the instructions)?

b

Did the trust engage in a prior year in any of the acts described in 1a, other than excepted acts, that were

not corrected before January 1, 2004?

c

Does section 4947(b)(3)(A) or (B) apply? (See page 9 of the instructions.) (If “Yes,” check

the “N/A” box in questions 3 and 4.)

2

3 Taxes on excess business holdings (section 4943):

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

at any time during 2004?

a

b If “Yes,” did the trust have excess business holdings in 2004 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? 

Use Schedule C, Form 4720, to determine if the trust had excess business holdings in 2004.

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

a Did the trust invest during 2004 any amount in a manner that would jeopardize its charitable purpose? 

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, 2004?

b

5 Taxes on taxable expenditures (section 4945) and political expenditures (section 4955):

a During 2004 did the trust pay or incur any amount to:

(1)

(2)

(3)

(4)

(5)

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

4947(a)(2)(B)?

2

54 Did the trustee change the method of determining the fair market value of the assets? 

If “Yes,” attach an explanation.

55 Were any additional contributions received by the trust during 2004? 

If “Yes,” attach a schedule that lists the assets and the date(s) received.

Part VI-A

Part VI-B Statements Regarding Activities for Which Form 4720 May Be Required

File Form 4720 if any item is checked in the “Yes” column (to the right), unless an exception applies. 

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Engage in the sale or exchange, or leasing of property with a disqualified person?

Borrow money from, lend money to, or otherwise extend credit to (or accept it from)

a disqualified person?

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

Pay compensation to, or pay or reimburse the expenses of, a disqualified person?

Transfer any income or assets to a disqualified person (or make any of either available

for the benefit or use of a disqualified person)?

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 termination

of government service, if terminating within 90 days.)

Provide for any purpose other than religious, charitable, scientific, literary, or

educational, or for the prevention of cruelty to children or animals?

Provide a grant to an organization other than a charitable, etc., organization described

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

Provide a grant to an individual for travel, study, or other similar purposes?

Influence the outcome of any specific public election (see section 4955); or to carry

on, directly or indirectly, any voter registration drive?

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

N/A

Organizations relying on a current Notice regarding disaster assistance, check here 

N/A

51a Total accrued distribution deficiencies from previous years (see page 8 of the instructions)

52 Unitrust distributions for 2004

53 Carryover of distribution deficiency (subtract line 52 from line 51b) 53

b Add lines 49b and 51a

52

51

51
Form 5227 (2004) 

Questionnaire for Charitable Lead Trusts, Pooled Income Funds, and Charitable Re

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? 

2 Enter the amount of any excess income required to be paid for charitable purposes for 2004 2

3

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

for 2004

3

4

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

2004

4

Section B—Pooled Income Funds

1 Enter the amount of contributions received during 2004 1

2 Enter the amount required to be distributed for 2004 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 2004 4

5 Enter the amount of income required to be paid to the charitable remainder beneficiary for 2004 5

Part VII

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

charitable interests involve only cemeteries or war veterans’ posts 

Check this box if any of the split-interest trust’s income interests expired during 2004 

If any answer is “Yes” to 5a(1)—(5), did any of the transactions fail to qualify under the exceptions described

in Regulations section 53.4945, or in a current Notice regarding disaster assistance (see page 9 of the

instructions)?

5b

If the answer is “Yes” to question 5a(4), does the trust claim exemption from the tax

because it maintained expenditure responsibility for the grant? (See page 9 of the

instructions.)

c

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

Yes No

Organizations relying on a current Notice regarding disaster assistance, check here 

Check this box if you are making an election under Regulations section 1.664-2(a)(1)(i)(a)(2) or 1.664-3(a)(1)(

treat income generated from certain property distributions (other than cash) by the trust as occurring on the 

of the tax year. (See page 10 of the instructions.) 

1

2

3

(All split-interest trusts, check applicable boxes.)

Section C—Charitable Remainder Trusts and Other Information

6

a

b

Personal benefit contracts (section 170(f)(10)):

Did the trust, during the year, receive any funds, directly or indirectly, to pay premiums

on a personal benefit contract? Yes No

Did the trust, during the year, pay premiums, directly or indirectly, on a personal benefit contract?

If “ Yes” to 6b, file Form 8870 (see instructions).

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

knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than trustee) is based on all informa

Sign has any knowledge.

Here

Signature of trustee or officer representing trustee 

Check if selfemployed

Date Prepa

Preparer’s

signature

Paid

Preparer’s

Use Only Firm’s name (or yours

if self-employed),

address, and ZIP code

EIN

Phone no. (