Form 5227

Department of the Treasury 

Internal Revenue Service 

Split-Interest Trust Information Return

▶ See separate instructions.

▶ Information about Form 5227 and its instructions is at www.irs.gov/form5227.

OMB No. 1545-0196

2012

Open to Public 

Inspection 

Full name of trust 

Name of trustee 

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

City, state, and ZIP code 

A Employer identification number 

B Type of Entity 

(1) Charitable lead trust 

(2) Charitable remainder annuity trust 

described in section 664(d)(1) 

(3) Charitable remainder unitrust 

described in section 664(d)(2) 

(4) Pooled income fund described in 

section 642(c)(5) 

C Fair market value (FMV) of assets at end of tax year D (5) Other—Attach explanation Gross Income 

E Check applicable 

boxes (see 

instructions) 

Initial return Final return Amended return 

Change in trustee’s ▶ Name Address 

F Date the trust was created 

G If the trust is a section 664 trust, did it have unrelated business taxable income? If “Yes,” file Form 4720 Yes No 

Part I Income and Deductions (All trusts complete Sections A through D) 

Section A—Ordinary Income 

1 Interest income . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

2a Ordinary dividends (including qualified dividends) . . . . . . . . . . . . . . . . 2a 

b Qualified dividends (see the instructions) . . . . . . . . . . 2b 

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. List type and amount ▶ 7 

8 Total ordinary income. Combine lines 1, 2a, and 3 through 7 . . . . . . . . . . . ▶ 8 

Section B—Capital Gains (Losses) 

9 Total short-term capital gain or (loss). Attach Schedule D, Part I (Form 1041) . . . . . . . 9 

10 Total long-term capital gain or (loss). Attach Schedule D, Part II (Form 1041) . . . . . . . . 10 

11 Unrecaptured section 1250 gain . . . . . . . . . . . . . 11 

12 28% gain . . . . . . . . . . . . . . . . . . . . . 12 

13 Total capital gains (losses). Combine lines 9 and 10 . . . . . . . . . . . . . . ▶ 13 

Section C—Nontaxable Income 

14 Tax-exempt interest . . . . . . . . . . . . . . . . . . . . . . . . . . 14 

15 Other nontaxable income. List type and amount ▶

15 

16 Total nontaxable income. Add lines 14 and 15 . . . . . . . . . . . . . . . . ▶ 16 

Section D—Deductions 

17 Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

18 Taxes (see the instructions) . . . . . . . . . . . . . . . . . . . . . . . . 18 

19 Trustee fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

20 Attorney, accountant, and return preparer fees . . . . . . . . . . . . . . . . . 20 

21 Other allowable deductions. Attach schedule (see the instructions) . . . . . . . . . . . 21 

22 Total. Add lines 17 through 21 . . . . . . . . . . . . . . . . . . . . . . . 22 

23 Charitable deduction . . . . . . . . . . . . . . . . . 23 

Section E—Deductions Allocable to Income Categories (Section 664 trust only) 

24a Enter the amount from line 22 allocable to ordinary income . . . . . . . . . . . . . 24a 

b Subtract line 24a from line 8 . . . . . . . . . . . . . . . . . . . . . . . 24b 

25 a Enter the amount from line 22 allocable to capital gains (losses) . . . . . . . . . . . . 25a 

b Subtract line 25a from line 13 . . . . . . . . . . . . . . . . . . . . . . . 25b 

26 a Enter the amount from line 22 allocable to nontaxable income . . . . . . . . . . . . 26a 

b Subtract line 26a from line 16 . . . . . . . . . . . . . . . . . . . . . . . 26b 

For Paperwork Reduction Act Notice, see the instructions. Cat. No. 13227T Form 5227 (2012) 
Form 5227 (2012) Page 2 

Part II Schedule of Distributable Income (Section 664 trust only) See the instructions 

 Accumulations (a) Ordinary 

income 

(b) Capital gains 

(losses) 

(c) Nontaxable 

income 

27 Undistributed income from prior tax years . . . . . . . .

28 Current tax year net income (before distributions): 

• In column (a), enter the amount from line 24b 

• In column (b), enter the amount from line 25b 

• In column (c), enter the amount from line 26b

29 Total distributable income. Add lines 27 and 28 . . . . . .

Part III-A Distributions of Principal for Charitable Purposes 

30 Principal distributed in prior tax years for charitable purposes . . . . . . . . . . . . 30 

31 Principal distributed during the current tax year for charitable purposes. Fill in the information for 

columns (A), (B), and (C) and enter the amount distributed on the space to the right. (see the 

instructions) 

 (A) 

Payee’s name and address 

(B) 

Date of distribution 

(C) 

Charitable purpose and description of assets distributed 

a 

31a 

b 

31b 

c 

31c 

32 Total. Add lines 30 through 31c . . . . . . . . . . . . . . . . . . . . . . 32 

Part III-B Accumulated Income Set Aside and Income Distributions for Charitable Purposes 

Grantor type trusts complete only lines 35 and 36 (see the instructions). 

33a Accumulated income set aside in prior tax years for which a deduction was claimed under 

section 642(c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33a 

b Enter the amount shown on line 23 . . . . . . . . . . . . . . . . . . . . . 33b 

34 Add lines 33a and 33b . . . . . . . . . . . . . . . . . . . . . . . . . 34 

35 Distributions made during the tax year (see the instructions): 

• For income set aside in prior tax years for which a deduction was claimed under section 642(c),

• For charitable purposes for which a charitable deduction was claimed under section 642(c) in

the current tax year, or

• For charitable purposes by a grantor type trust for which a charitable deduction was claimed 

under section 170 upon contribution to the trust

Fill in the information for columns (A), (B), and (C) and enter the amount distributed on the line 

to the right. 

 (A) 

Payee’s name and address 

(B) 

Date of distribution 

(C) 

Charitable purpose and description of assets distributed 

a 

35a 

b 

35b 

c 

35c 

36 Add lines 35a through 35c . . . . . . . . . . . . . . . . . . . . . . . . 36 

37 Carryover. Subtract line 36 from line 34 . . . . . . . . . . . . . . . . . . . . 37 

Form 5227 (2012) 
Form 5227 (2012) Page 3 

Part IV Balance Sheet (see the instructions) 

 Assets (a) Beginning-ofYear Book Value 

(b) End-of-Year 

Book Value 

(c) FMV (see 

instructions)

38 Cash—non-interest-bearing . . . . . . . . . . . . . . . 38 

39 Savings and temporary cash investments . . . . . . . . . . 39 

40a Accounts receivable . . . . . . . . . . 40a 

b Less: allowance for doubtful accounts . . . . 40b 

41 Receivables due from officers, directors, trustees, and other 

disqualified persons (attach schedule) . . . . . . . . . . . 41 

42a Other notes and loans receivable . . . . . 42a 

b Less: allowance for doubtful accounts . . . 42b 

43 Inventories for sale or use . . . . . . . . . . . . . . . 43 

44 Prepaid expenses and deferred charges . . . . . . . . . . 44 

45a Investments—U.S. and state government obligations (attach 

schedule) . . . . . . . . . . . . . . . . . . . . . 45a 

b Investments—corporate stock. Attach schedule . . . . . . . . 45b 

c Investments—corporate bonds. Attach schedule . . . . . . . . 45c 

46a Investments—land, buildings, and equipment: 

basis (attach schedule) . . . . . . . . 46a 

b Less: accumulated depreciation . . . . . 46b 

47 Investments—other (attach schedule) . . . . . . . . . . . 47 

48a Land, buildings, and equipment: basis . . . 48a 

b Less: accumulated depreciation . . . . . 48b 

49 Other assets. Describe ▶ 49 

50 Total assets. Add lines 38 through 49 (must equal line 60) . . . ▶ 50 

 Liabilities 

51 Accounts payable and accrued expenses . . . . . . . . . . 51 

52 Deferred revenue . . . . . . . . . . . . . . . . . . 52 

53 Loans from officers, directors, trustees, and other disqualified persons 53 

54 Mortgages and other notes payable. Attach schedule . . . . . . 54 

55 Other liabilities. Describe ▶ 55 

56 Total liabilities. Add lines 51 through 55 . . . . . . . . . ▶ 56 

 Net Assets 

57 Trust principal or corpus . . . . . . . . . . . . . . . . 57 

58a Undistributed income . . . . . . . . . . . . . . . . . 58a 

b Undistributed capital gains . . . . . . . . . . . . . . . 58b 

c Undistributed nontaxable income . . . . . . . . . . . . . 58c 

59 Total net assets. Add lines 57 through 58c . . . . . . . . . 59 

60 Total liabilities and net assets. Add lines 56 and 59 . . . . . . 60 

Form 5227 (2012) 
Form 5227 (2012) Page 4 

Part V-A Charitable Remainder Annuity Trust (CRAT) Information (to be completed only by a section 

664 CRAT) 

61 a Enter the initial fair market value (FMV) of the property placed in the trust . . . . . . . . . . 61a 

b Enter the total annual annuity amounts for all recipients . . . . . . . . . . . . . . . 61b 

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

See the instructions 

62 Is the CRUT a net income charitable remainder unitrust (NICRUT) as described in Regulations section 

1.664-3(a)(1)(i)(b)(1)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 

63 Is the CRUT a net income with make-up charitable remainder unitrust (NIMCRUT) as described in Regulations 

section 1.664-3(a)(1)(i)(b)(2)? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 

64 Did the trust change its method of payment during the tax year? . . . . . . . . . . . . . . Yes No 

If “Yes,” describe the triggering event including the date of the event and the old method of payment ▶

65 a Enter the unitrust fixed percentage to be paid to the recipients . . . . . . . . . . . . . 65a % 

b Unitrust amount. Subtract line 56, column (c), from line 50, column (c), and multiply the result by the 

percentage on line 65a. Do not enter less than -0- . . . . . . . . . . . . . . . . . 65b 

If the answer is “Yes” on line 62 or line 63, go to line 66a. Otherwise, skip lines 66a through 67b 

and enter the line 65b amount on line 68. 

66a Trust’s accounting income for 2012. Attach schedule . . . . . . . . . . . . . . . . 66a 

If the answer is “Yes” on line 62, go to line 66b. If the answer is “Yes” on line 63, skip line 66b 

and go to line 67a. 

b Enter the smaller of line 65b or line 66a here and on line 68. Skip lines 67a and 67b . . . . . . 66b 

67a Total accumulated distribution deficiencies from previous years (see the instructions) . . . . . . 67a 

b Add lines 65b and 67a . . . . . . . . . . . . . . . . . . . . . . . . . . 67b 

If lines 67a and 67b are completed, enter the smaller of line 66a or line 67b on line 68. 

68 Required unitrust distribution for 2012 . . . . . . . . . . . . . . . . . . . . . 68 

69 Carryover of accumulated distribution deficiency (only for trusts that answered “Yes” on line 63). 

Subtract line 68 from line 67b . . . . . . . . . . . . . . . . . . . . . . . . 69 

70 If this is the final return, enter the initial FMV of all assets placed in trust by the donor . . . . . . 70 

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

If “Yes,” attach an explanation. 

72 Were any additional contributions received by the trust during 2012? . . . . . . . . . . . . . Yes No 

If “Yes,” be sure to complete all columns of line 7 in Schedule A, Part III. 

Part VI-A Statements Regarding Activities (see the instructions) 

73 Are the requirements of section 508(e) satisfied either: Yes No

• 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? . . . . . . . . . . . . . . 73

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

4947(a)(2)(B)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 

Form 5227 (2012) 
Form 5227 (2012) Page 5 

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 

75 Self-dealing (section 4941): 

a During 2012, did the trust (either directly or indirectly): 

(1) Engage in the sale or exchange, or leasing of property with a disqualified person? Yes No 

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

a disqualified person? . . . . . . . . . . . . . . . . . . . . . Yes No 

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? . Yes No 

(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? . Yes No 

(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)? . . . . . . . . . . . . . Yes No 

(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 termination 

of government service, if terminating within 90 days.) . . . . . . . . . . . . Yes No 

b If any answer is “Yes” to 75a(1) through (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 

instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75b 

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

c Did the trust engage in a prior year in any of the acts described in 75a, other than excepted acts, that were 

not corrected before January 1, 2012? . . . . . . . . . . . . . . . . . . . . . . . 75c 

76 Does section 4947(b)(3)(A) or (B) apply? (See the instructions.) . . . . . . . . . Yes No 

If “Yes,” check the “N/A” box in questions 77 and 78. 

77 Taxes on excess business holdings (section 4943): N/A 

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

any time during 2012? . . . . . . . . . . . . . . . . . . . . . . Yes No 

b If “Yes,” did the trust have excess business holdings in 2012 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? . . . . . . . . . . . . . . 77b 

Use Schedule C, Form 4720, to determine if the trust had excess business holdings in 2012. 

78 Taxes on investments that jeopardize charitable purposes (section 4944): N/A 

a Did the trust invest during 2012 any amount in a manner that would jeopardize its charitable purpose? . . 78a 

b 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, 2012? . . . . . . . 78b 

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

a During 2012, did the trust pay or incur any amount to: 

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? . Yes No 

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

on, directly or indirectly, any voter registration drive? . . . . . . . . . . . Yes No 

(3) Provide a grant to an individual for travel, study, or other similar purposes? . . . . Yes No 

(4) 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)? . . . . . . . . . . . . Yes No 

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

educational, or for the prevention of cruelty to children or animals? . . . . . . Yes No 

b If any answer is “Yes” to 79a(1) through (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 the

instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79b 

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

c If the answer is “Yes” to question 79a(4), does the trust claim exemption from the tax 

because it maintained expenditure responsibility for the grant? . . . . . . . . . Yes No 

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

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

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

a personal benefit contract? . . . . . . . . . . . . . . . . . . . . Yes No 

b Did the trust, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . . . 80b 

If “Yes” to 80b, file Form 8870 (see the instructions.) 

Form 5227 (2012) 
Form 5227 (2012) Page 6 

Part VII Questionnaire for Charitable Lead Trusts, Pooled Income Funds, and Charitable Remainder Trusts 

(see the instructions) 

Section A—All Trusts 

81 Check this box if any of the split-interest trust’s income interests expired during 2012 . . . . . . . . . ▶

82 Check this box if all of the split-interest trust’s income interests expired before 2012 . . . . . . . . . . ▶

If 82 (above) is checked and this is not a final return, attach an explanation. 

Section B—Charitable Lead Trusts 

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

paid for charitable purposes? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 

84 Enter the amount of any excess income required to be paid for charitable purposes for 2012 . . . 84 

85 Enter the amount of annuity or unitrust payments required to be paid to charitable beneficiaries for 2012 . 85 

Section C—Pooled Income Funds 

86 Enter the amount of contributions received during 2012 . . . . . . . . . . . . . . 86 

87 Enter the amount required to be distributed for 2012 to satisfy the remainder interest . . . . . 87 

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

undistributed . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 

89 Enter the amount of income required to be paid to the charitable remainder beneficiary for 2012 . 89 

Section D—Charitable Remainder Trusts 

90 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 . . . . . . . . . . . . . . . . ▶

91 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)(i)(g)(2) to 

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

of the tax year. (See the instructions.) . . . . . . . . . . . . . . . . . . . . . . . . . ▶

92 Is this the initial return? If “Yes,” attach a copy of the trust instrument . . . . . . . . . . . . . Yes No 

93 Was the trust instrument amended during the year? If “Yes,” attach a copy . . . . . . . . . . . Yes No 

94a If this is the final return, were final distributions made according to the trust instrument? . . . . . . . Yes No 

b If “Yes,” did you complete line 31? . . . . . . . . . . . . . . . . . . . . . . . . Yes No 

c If either line 94a or 94b is “No,” explain why ▶

95 At any time during calendar year 2012, did the trust have an interest in or a signature or other authority over a 

bank, securities, or other financial account in a foreign country? . . . . . . . . . . . . . . . Yes No 

See the instructions for exceptions and filing requirements for Form TD F 90-22.1. 

If “Yes,” enter the name of the foreign country ▶

Sign 

Here 

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

has any knowledge. 

▲

Signature of trustee or officer representing trustee ▲

Date 

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer’s signature Date Check if 

self-employed 

PTIN

Firm’s name ▶

Firm’s address ▶

Firm's EIN ▶

Phone no. 

Form 5227 (2012) 
Form 5227 (2012) Page 7 

Full name of trust Employer identification number 

NOT Open To Public Inspection 

Schedule A—Distributions, Assets, and Donor Information 

Part I Accumulation Schedule (Section 664 trust only) See the instructions 

 Accumulations (a) 

Ordinary income 

(b) 

Capital gain (loss) 

(c) 

Nontaxable income 

1 Total distributable income. Enter the amount from line 29 . . .

2a Total distributions for 2012: 

b 2012 distributions from income . . . . . . . . . . .

3 Undistributed income at end of tax year. Subtract line 2b from 

line 1 . . . . . . . . . . . . . . . . . . . .

Part II-A Current Distributions Schedule (Section 664 trust only) See the instructions

(a) 

Name of recipient 

(b) 

Identifying number 

(c) 

Percentage of total unitrust 

amount payable (if applicable) 

4a % 

b % 

c % 

(d) 

Ordinary Income 

Capital gains 

(g) 

Nontaxable Income 

(h) 

Corpus 

(i) 

Total (add cols. 

(d) through (h))

 (e) Short-term (f) Long-term 

4a 

b 

c 

Total 

If Part II-A, Total, column (i) does not agree with line 61b of Form 5227 for a CRAT or line 68 of Form 5227 for a CRUT, check 

here ▶ and attach an explanation. 

Part II-B Current Distributions (charitable lead trusts or pooled income funds only) See the instructions 

5 Enter the amount required to be paid to private beneficiaries for 2012 . . . . . . . . . . ▶

Part III Assets and Donor Information (Section 664 trust or charitable lead trust only) 

6 Is this the initial return or were additional assets contributed to the trust in 2012? . . . . . . . . . Yes No 

If “Yes,” complete the schedule below. 

If “No,” complete only column (a) of the schedule below. 

(a) 

Name and address of donor 

(b) 

Description of each asset donated 

(c) 

Fair market value of each 

asset on date of donation 

(d) 

Date of donation 

7a 

7b 

7c 

7d Total . . . . . . . . . . . . . . . . . . . ▶

8 For charitable remainder trusts: If this was the final year, was an early termination agreement 

signed by all parties to the trust? . . . . . . . . . . . . . . . . . . . . . . Yes No N/A 

If “Yes,” attach a copy of the signed agreement. 

Form 5227 (2012)