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Form 1041-A (Rev. 2-2012) Page 2

Part IVBalance Sheets (see instructions). If line 9, page 1, is $25,000 or less, complete only lines 38, 42,and 45 (see instructions).

Assets (a) Beginning-of-Year Book Value

(b) End-of-YearBook Value

25 Cashnon-interest bearing . . . . . . . . . . . . . . . . . . 25

26 Savings and temporary cash investments . . . . . . . . . . . . . 26

27a Accounts receivable . . . . . . . . . . . . 27a

b Less: allowance for doubtful accounts . . . . . . 27b

28a Notes and loans receivable . . . . . . . . . . 28ab Less: allowance for doubtful accounts . . . . . . 28b

29 Inventories for sale or use . . . . . . . . . . . . . . . . . . 29

30 Prepaid expenses and deferred charges . . . . . . . . . . . . . 30

31 InvestmentsU.S. and state government obligations (attach schedule) . . . 31

32 Investmentscorporate stock (attach schedule) . . . . . . . . . . . 32

33 Investmentscorporate bonds (attach schedule) . . . . . . . . . . . 33

34a Investmentsland, buildings, and equipment: basis . . 34a

b Less: accumulated depreciation . . . . . . . . 34b

35 Investmentsother (attach schedule) . . . . . . . . . . . . . . 35

36a Land, buildings, and equipment: basis . . . . . . 36a

b Less: accumulated depreciation . . . . . . . . 36b

37 Other assets (describe ) 37

38 Total assets (add lines 25 through 37) . . . . . . . . . . . . . 38Liabilities

39 Accounts payable and accrued expenses . . . . . . . . . . . . . 39

40 Mortgages and other notes payable (attach schedule) . . . . . . . . . 40

41 Other liabilities (describe ) 41

42 Total liabilities (add lines 39 through 41) . . . . . . . . . . . . . 42

Net Assets43 Trust principal or corpus . . . . . . . . . . . . . . . . . . . 43

44 Undistributed income and profits . . . . . . . . . . . . . . . . 44

45 Total net assets (add lines 43 and 44) . . . . . . . . . . . . . . 4546 Total liabilities and net assets (add lines 42 and 45) . . . . . . . . . 46

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 knowledgeand 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

Form 1041-A(Rev. 2-2012

PaidPreparerUse Only

Print/Type preparers name Preparers signature DateCheck ifself- employed

PTIN

Firms name

Firms address

Firm's EIN

Phone no.

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Form 1041-A (Rev. 2-2012) Page 3

Whats NewFuture developments. The IRS hascreated a page on IRS.gov forinformation about Form 1041-A and itsinstructions, at www.irs.gov/form1041.Information about any futuredevelopments affecting Form 1041-A(such as legislation enacted after werelease these instructions) will be posted

on that page.

ReminderSplit-interest trusts as described insection 4947(a)(2) do not file Form1041-A. These types of trusts file Form5227, Split-Interest Trust InformationReturn, which meets the section 6034filing requirements.

General InstructionsSection references are to the InternalRevenue Code unless otherwise noted.

Purpose of FormUse Form 1041-A to report thecharitable information required bysection 6034 and the related regulations.

Who Must FileThe trustee must file Form 1041-A for atrust that claims a charitable or otherdeduction under section 642(c) unlessan exception applies.

Exceptions. The trustee does not fileForm 1041-A for:

A trust that is required to distributecurrently to the beneficiaries all theincome for the tax year determinedunder section 643(b) and relatedregulations,

A charitable trust described in section4947(a)(1), or

For tax years beginning after 2006, asplit-interest trust described in section4947(a)(2).

When To FileFile Form 1041-A by April 15 followingthe close of the calendar year. If the duedate falls on a Saturday, Sunday, orlegal holiday, file on the next businessday.

Extension of Time To FileThe trustee may obtain an automatic3-month extension of time to file Form1041-A by filing Form 8868, Applicationfor Extension of Time to File an ExemptOrganization Return. To receive theautomatic 3-month extension, thetrustee must file Form 8868 on or beforethe original due date of Form 1041-A.

If more time is needed after theautomatic extension, file a second Form8868 to request an additional (notautomatic) 3-month extension. This willbe granted only if you can show

reasonable cause as to why the returncannot be filed by the already extendeddue date.

Amended Return

If you are filing an amended Form1041-A, you must complete the entirereturn, not just the new or correctedinformation. Enter Amended Returnacross the top of the amended Form1041-A.

The trustee may file an amendedreturn at any time to change or add tothe information reported on a previouslyfiled return for the same period.

Where To FileFile Form 1041-A at the followingaddress:

Department of the TreasuryInternal Revenue Service CenterOgden, UT 84201-0027

Penalties

Section 6652(c)(2) provides for separatepenalties of $10 a day, up to a maximumof $5,000, against both the trust and thetrustee for not filing Form 1041-A ontime, unless there is reasonable cause.The law also provides penalties for filinga false or fraudulent return.

Rounding Off to Whole Dollars

You may show the money items on thereturn and accompanying schedules aswhole-dollar amounts. To do so, dropamounts less than 50 cents andincrease any amounts from 50 to 99cents to the next dollar.

AttachmentsIf you need more space, attach separatesheets showing the same information inthe same order as on the printed forms.Show the totals on the printed forms.

Enter the trusts employeridentification number (EIN) on eachsheet. Also, use sheets that are thesame size as the forms and indicateclearly the line of the printed form towhich the information relates.

Public Inspection

See Regulations section 301.6104(b)1(d) for the procedures to request public

inspection of this form.

Specific InstructionsPart II. Distributions of IncomeSet Aside For CharitablePurposes

Lines 17a17e. Provide a listing insufficient detail for each class of activityfor which a disbursement was made,and a charitable deduction under section642(c) was taken.

Such amounts permanently set asidemust be earned from amountstransferred to the trust before October 9,1969.

Do not merely enter the category (thatis, religious, charitable, scientific, literaryor educational), but also enter thepurpose of the deduction. For example,payments of $4,000 to indigent persons

for medical purposes, or a grant of$25,000 to equip the chemistry lab at auniversity.

Part III. Distributions of Principalfor Charitable Purposes

Lines 23a23e. Provide a listing insufficient detail, similar to the examplesprovided above, for each class ofactivity for amounts paid out of principalfor charitable purposes.

See the instructions for Form 1041,U.S. Income Tax Return for Estates andTrusts, for more information regardingthe allowance of deductions for amounts

permanently set aside for a charitablepurpose.

Part IV. Balance Sheets

Complete the balance sheets using theaccounting method the trust uses inkeeping its books and records. All filersmust complete columns (a) and (b).

Assets

When space is provided to the left ofcolumn (a) for reporting receivables andthe related allowance for doubtfulaccounts or depreciable assets andaccumulated depreciation, enter theend-of-year figures.

Line 25. Cashnon-interest bearing.Enter the amount of cash on deposit inchecking accounts, deposits in transit,change funds, petty cash funds, or anyother non-interest bearing accounts. Donot include advances to employees orofficers or refundable deposits paid tosuppliers or others.

Line 26. Savings and temporary cashinvestments. Enter the total of cash insavings or other interest-bearingaccounts and temporary cashinvestments, such as money marketfunds, commercial paper, certificates ofdeposit, and U.S. Treasury bills or othergovernmental obligations that mature inless than 1 year.

Line 27. Accounts receivable. Enter thetotal accounts receivable (reduced bythe corresponding allowance for doubtfuaccounts) that arose from the sale ofgoods and/or the performance ofservices. Claims against vendors orrefundable deposits with suppliers orothers may be reported here if notsignificant in amount. If significant inamount, report them (with any advancesto employees or officers) on line 37,Other assets.

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Form 1041-A (Rev. 2-2012) Page 4

Line 28. Notes and loans receivable.Enter the combined total of notesreceivable and net loans receivable(including receivables due from officers,directors, trustees, and other disqualifiedpersons). In an attached schedule, showthe following information (preferably incolumnar format):

Borrowers name and title,

Original amount, Balance due,

Date of note,

Maturity date,

Repayment terms,

Interest rate,

Security provided by the borrower,

Purpose of the loan, and

Description and fair market value ofthe consideration furnished by thelender.

Line 29. Inventories for sale or use.Enter the amount of materials, goods,and supplies purchased or manufacturedby the trust and held for sale or use insome future period.

Line 30. Prepaid expenses anddeferred charges. Enter the amount ofshort-term and long-term prepaymentsof future expenses attributable to one ormore future accounting periods.Examples include prepayments of rent,insurance, and pension costs.

Lines 31, 32, and 33. Investmentsgovernment obligations, corporatestocks, and corporate bonds. Enter thebook value (which may be market value)of these investments. Attach a schedule

that lists each security held at the end ofthe year and shows whether the securityis listed at cost (including the valuerecorded at the time of receipt in thecase of donated securities) orend-of-year market value. Do not includeamounts on line 26. Governmentobligations reported on line 31 are thosethat mature in 1 year or more. Debtsecurities of the U.S. government maybe reported as a single total rather thanitemized. Obligations of state andmunicipal governments may also bereported as a lump-sum total. Do notcombine U.S. government obligationswith state and municipal obligations on

the attached schedule.Line 34. Investmentsland, buildings,and equipment.Attach a schedule of allland, buildings, and equipment that areheld for investment purposes, such asrental properties. List the cost or otherbasis of these assets, accumulateddepreciation, and end-of-year bookvalue.

Line 35. Investmentsother. Enter theamount of all other investment holdingsnot reported on lines 31 through 34.Attach a schedule describing each ofthese investments held at the end of theyear. List the cost, or other basis, andthe end-of-year book value.

Line 36. Land, buildings, andequipment.Attach a schedule of all

land, buildings, and equipment that arenot held for investment purposes, suchas the trusts offices. List the cost orother basis of these assets, accumulateddepreciation, and end-of-year bookvalue.

Line 37. Other assets. Enter the bookvalue of any trust assets that have notbeen reported on lines 25 through 36. Ifmore space is needed, attach a separateschedule with a description of the asset,date acquired, and end-of-year bookvalue.

Liabilities

Line 39. Accounts payable andaccrued expenses. Enter the totalaccounts payable to suppliers andothers, and accrued expenses such assalaries payable, accrued payroll taxes,and interest payable.

Line 40. Mortgages and other notespayable.Attach a schedule showing, asof the end of the year, the total amountof all mortgages payable, and for eachnonmortgage note payable, the lendersname and the other information specifiedin the line 28 instructions.

Line 41. Other liabilities. Enter the bookvalue of any trust liabilities that have not

been reported on lines 39 or 40. If morespace is needed, attach a separateschedule with a description of theliability and amount.

Signature

Form 1041-A must be signed by thetrustee or by an authorizedrepresentative.

If you, as trustee (or an employee orofficer of the trust), fill in Form 1041-A,the Paid Preparer space should be leftblank. If someone prepares this returnwithout charge, that person should notsign the return.

Generally, anyone who is paid toprepare a tax return must sign the returnand fill in the other blanks in the PaidPreparer Use Onlyarea of the return.

If you have questions about whether apreparer is required to sign the return,please contact an IRS office.

The person signing the return as thepreparer should complete the requestedpreparer information and:

Sign it in the space provided for thepreparers signature. (A facsimilesignature is acceptable.)

Give the trustee a copy of the return inaddition to the copy to be filed with theIRS.

Paperwork Reduction Act Notice. Weask for the information on this form tocarry out the Internal Revenue laws ofthe United States. You are required togive us the information. We need it toensure that you are complying withthese laws and to allow us to figure andcollect the right amount of tax.

You are not required to provide theinformation requested on a form that is

subject to the Paperwork Reduction Actunless the form displays a valid OMBcontrol number. Books or recordsrelating to a form or its instructions mustbe retained as long as their contentsmay become material in theadministration of any Internal Revenuelaw. Generally, tax returns and returninformation are confidential, as requiredby Code section 6103.

The time needed to complete and filethis form will vary depending onindividual circumstances. The estimatedaverage time is:

Recordkeeping . . . 24 hr., 52 min

Learning about thelaw or the form . . . . 2 hr., 37 min

Preparing the form . . 7 hr., 48 min

Copying, assembling,and sending theform to the IRS . . . . 1 hr., 20 min

If you have comments concerning theaccuracy of these time estimates orsuggestions for making this formsimpler, we would be happy to hearfrom you. You can write to the TaxProducts Coordinating Committee,SE:W:CAR:MP:T:M:S, IR-6526, 1111Constitution Ave. NW, Washington, DC20224. Do not send the tax form to this

address. Instead, see Where To Fileearlier.