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ANNUAL STATEMENT
OF THE
Segregated Gift Annuity Fund
OF THE
CHARITABLES
Of
In the State of
TO THE
INSURANCE DEPARTMENT
OF THE
STATE OF NEW YORK
For the Year Ended December 31, 2007
2007
ANNUAL STATEMENT
For The Year Ended December 31, 2007
OF THE CONDITION AND AFFAIRS OF THE
Segregated Gift Annuity Fund
OF THE
NAIC Company Code: Employer's ID Number:
Organized under the Laws of the State of made to the
Insurance Department of the State of New York
PURSUANT TO THE LAWS THEREOF
Incorporated/Organized Commenced Business
Mailing Address:
(Street and Number) (City or Town, State and Zip Code)
Administrative Office:
(Street and Number) (City or Town, State and Zip Code)
(Area Code) (Telephone Number)
Contact Person, Phone Number and E-mail address:
OFFICERS 1
{
President 2
Title 3
Secretary 2
Title 3
2
Treasurer
Title 3
DIRECTORS OR TRUSTEES 1
STATE OF
COUNTY OF } SS
President 2, Secretary 2, Treasurer 2
of the ……………………………………………………, being duly sworn, each for himself deposes and says that they are the above
described officers of the said reporting entity, and that on the thirty-first day of December last, all of the above described assets were
segregated and held as a separate and distinct fund (subject to appropriation by the reporting entity of funds legally transferable to the
general funds thereof) free and clear from any liens or claims thereon, except as above stated, as required by the provisions of Section
1110 of the New York Insurance Law, and that the foregoing statement, with the schedules and explanations therein contained, annexed
or referred to is a full and correct exhibit of all of the assets, liabilities, income and disbursements, and of the condition and affairs of the
said reporting entity’s segregated gift annuity fund on the said thirty-first day of December last, and for the year ended on that date,
according to the best of their information, knowledge and belief, respectively.
The UNDERSIGNED further certify, according to the best of their knowledge and belief, that the Annual Statement electronic
filing submitted for the reporting stated above is identical to the information contained in the 2007 Annual Statement blank filed with the
New York State Insurance Department.
Subscribed and sworn to before me this …………………..………..
day of ……………………………...………..…………, 20 ……… }
President 2
Secretary 2
2
Treasurer
Agent for Service of Process
Address
1
Show full name (initials are not acceptable).
2
Or a corresponding officer of the reporting entity.
3
Indicate title, if a corresponding officer.
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
Current Year Prior Year
ASSETS
1. Market Value of bonds (Schedule A, Part 1, Column 7) ………………………………………...……
2. Market Value of preferred stocks (Schedule A, Part 2, Column 7) ……………………...…………..
3. Market Value of common stocks (Schedule A, Part 3, Column 7) …………………………………..
4. Market Value of money market mutual funds (Schedule B, Column 9) …………………….……….
5. Market Value of other invested assets (Schedule D, Part 1, Column 4) …………………..…………
6. Cash (Schedule C, Column 6)
6.1 Cash in office ………………………………………………………………….…...…………….
6.2 Cash on deposit …………………………………………..………………..………………….…
7. Investment income due or accrued (Exhibit 1, Column 3, Line 3) …….………..……………….……
8. Miscellaneous assets:
8.1
8.2
8.3
8.4
9. Total Assets (sum of lines 1 to 8) …………………………………..……..…..……………..………… 0 0
Current Year Prior Year
LIABILITIES AND ANNUITY FUND BALANCE
10. Net present value of annuities 1 ………………………………………..….…....…..……....…………
11. Deduct net value of risks reinsured 2 ……………………….…..……..….…..….………..……….…
12. NET RESERVE (line 10 minus line 11) ………………………………………....…………….….…
13. Annuity payments due and unpaid …………………………………………………………….…….
14. Deposits received from donors pending issuance of annuity agreements …..………….…..……
15. General expenses due or accrued ……………………………..…….….….….….….…...……….…..
16. Taxes due or accrued …………………………………………..…..……………...…...….….….…….
17. Unearned investment income ………………………….….….….……………………….….…..……
18. Miscellaneous liabilities:
18.1
18.2
18.3
18.4
19. Total Liabilities (sum of lines 12 to 18) …………….………….….….….….….….....….……….…. 0 0
20. Annuity Fund Balance:
20.1 Minimum required fund balance ……………………..………………...….….….………………
20.2 Excess fund balance (surplus) ……………………………………...…...…...……....….….……
20.3 Total Annuity Fund Balance (sum of lines 20.1 and 20.2) ………….…...……………...……. 0 0
21. Total Liabilities and Annuity Fund Balance (sum of lines 19 and 20.3; should equal Line 9) … 0 0
1
Attach a listing that includes complete details relative to mortality tables, valuation interest rates, etc.
2
See Annual Statement Instructions for "Page 2, Line 11, Reinsurance"
2
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
Current Year Prior Year
INCOME
1. Amount of gifts received during the year conditioned upon annuity agreements ……..….....……..…………
2. Investment income (Exhibit 1, Column 3, Line 7) …………………………………………………..…….…………………
3. Realized capital gains/(losses) ………………………………………………………………….……………………
4. Unrealized capital gains/(losses) (Exhibit 2, Column 5, Line 16) ……………….…..……….…………………….
5. Other income:
5.1
5.2
5.3
5.4
6. Gross amount transferred from general funds of the corporation ……………..…..…………….…..….……….
7. Total Income (sum of lines 1 to 6) …………….………………………..…….…..………………..……………….. 0 0
DISBURSEMENTS
8. Annuity payments to donors and others ……………………………..……...…....…..…….…….…………….
9. General expenses ……………………………………………...……….…..……..….…..….………………………
10. Other expenses and disbursements:
10.1
10.2
10.3
10.4
11. Gross amount transferred to general funds of the corporation …………..………..………..….…………….
12. Total Disbursements (sum of lines 8 to 11) ……………….………………………………...…………………. 0 0
13. Net change in Annuity Fund (line 7 minus line 12) ………………………………………...……..….….……. 0 0
14. Prior year Annuity Fund Balance ……………………………………………...…..……………….……………
15. Annuity Fund Balance at end of year (sum of lines 13 and 14) …………………….…...….….….….……… 0 0
EXHIBIT OF ANNUITIES IN FORCE
1 NUMBER AND ANNUALIZED AMOUNT OF ANNUITIES IN FORCE (OMIT CENTS)
AT DEC 31, At Beginning of Year Written During Year Terminated During Year At End of Year
YEAR ENDING RESERVE 2 3 4 5 6 7 8 9
No. Amount No. Amount No. Amount No. Amount
1. 2007
2. 2006
3. 2005
4. 2004
5. 2003
6. 2002
7. 2001
Note: For the year 2007, exclude California business. For the years 2006 and prior, report same amounts as were reported in the filed 2006 Annual Statement.
EXHIBIT OF ANNUITIES IN FORCE IN NEW YORK
Indicate the number, annualized amount of payments, and reserve thereon for annuities in force in New York State included in Line 1, Columns 1, 8 and 9 above:
1. Reserve
2. Number
3. Annualized amount of payments
3
3
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
GENERAL INTERROGATORIES
1. Total amount loaned by the segregated gift annuity fund during the year to directors, members of the
governing board or other officers. ..........................................................................................................
2. Total amount of loans outstanding at end of year to directors, members of the governing board or other officers.
3. Did any person while an officer, director, member of the governing board or trustee of the reporting entity
receive directly or indirectly, during the period covered by this statement, any commission on the business
transactions of the segregated gift annuity fund? If yes, explain................................................................. Yes No
4. Were any of the stocks, bonds or other assets of the segregated gift annuity fund loaned, placed under option
agreement, or otherwise made available for use by another person during the year covered by this statement?
If yes, give full and complete information relating thereto........................................................................... Yes No
5. Are the assets of the segregated gift annuity fund maintained in a separate and distinct account, physically
segregated from the other assets of the reporting entity, in the amount required by §1110(b) of the New York
State Insurance Law? ………………...................................................................................................... Yes No
5.1 Indicate name and address of Custodian: Name
Address
If no, explain:
6. State as of what date the latest examination of this segregated gift annuity fund was made or is being made…
6.1 By what insurance department or departments
7. Has any change been made during the year of this statement in the charter, articles of incorporation, or deed
of settlement of the reporting entity? …………………….......................................................................... Yes No
If not previously filed, furnish herewith a certified copy of the instrument as amended.
8. Has there been any change in the name of the reporting entity since the date of the last statement filed with
the Department? ……………………....................................................................................................... Yes No
*8.1 If yes, indicate prior name
current name
*See Instructions For Completing the New York State Segregated Gift Annuity Fund Annual Statement, General Interrogatories
9. What officials and heads of departments of the reporting entity supervised the making of this report?
Answer:
10. In what states, territories, or foreign countries is the segregated gift annuity fund authorized to issue
charitable gift annuities?
Answer:
11. Is the segregated gift annuity fund authorized to issue charitable gift annuities in states that require a separate
trust account for the maintenance of assets for the sole benefit of its residents, e.g., California? .................. Yes No
11.1 If yes, has the segregated gift annuity fund followed the special directions given in the Instructions
For Completing the New York State Segregated Gift Annuity Fund Annual Statement for reporting
information on annuities issued in such states? .........................……………………………….…….... Yes No
12. Has the segregated gift annuity fund issued annuities conditioned upon receipt of gifts other than cash,
cash equivalents, mutual funds, bonds or stocks? ..…......…......…......…......…......…......…......…........… Yes No
12.1 If yes, has the segregated gift annuity fund completed Schedule D? ...…...…......…......….........…..... Yes No
13. Has the segregated gift annuity fund followed the Instructions for reporting Reserves on Page 2 and submitted
a listing that includes complete details relative to the mortality tables; valuation interest rates, etc. in compliance
with the Instructions For Completing the New York State Segregated Gift Annuity Fund Annual Statement? Yes No
14. In accordance with Section 1110(a) of the New York Insurance Law, every “corporation or association shall,
before making such agreement, file with the superintendent copies of its forms of agreements with annuitants..”
14.1 Have all agreements and forms in use for the issue of annuities in New York State been filed with the
Superintendent? ............................................................................................................................. Yes No
If no, refer to the Instructions For Completing the New York State Segregated Gift Annuity Fund
Annual Statement.
Note: Each individual society must file its forms with the Superintendent. This includes any
revised or updated versions of the forms. There are no “pre-approved” forms currently
available in New York and the Superintendent does not pre-approve or endorse any
particular form-drafting software.
15. Is the purchase and sale of all investments of the segregated gift annuity fund approved within an approved
investment policy and reviewed periodically either by its governing body or a subordinate committee thereof? Yes No
If so, name the committee
16. Does the reporting entity keep a complete permanent record of the proceedings of its governing body and all
subordinate committees thereof? ...…......…......…......…......…......…......…......…......….........…......….. Yes No
17. Has the segregated gift annuity fund reinsured any of its annuity contracts? If yes, complete Schedule E. ….. Yes No
4
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
NOTES TO FINANCIAL STATEMENTS
Refer to the Instructions For Completing the New York State
Segregated Gift Annuity Fund Annual Statement
for directions on the information that must be reported on this page.
Each note must be included and numbered in accordance with the Instructions For Completing the New York State
Segregated Gift Annuity Fund Annual Statement. If there is nothing to report at a Note, do not omit the Note, indicate
"None" or "NA" at the appropriate Note number.
1.
2.
3.
5
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
EXHIBIT 1 --- VERIFICATION OF INVESTMENT INCOME
1 2 3 4 5 6 7 8
Cash, Other
Line Money Market and Money Market Invested
# Total Certificates of Deposit Bonds Stocks Mutual Funds Assets
1. Interest and dividends received during the year
2. Interest/dividends received on bonds, stocks, and other invested assets
sold or otherwise disposed of during the year XXX XXX
3. Interest due or accrued and dividends declared and unpaid, at end of
current year XXX XXX
4. Gross investment income (sum of lines 1 to 3) 0 0 0 0 0 0
Deduct:
5. Paid for accrued interest and dividends on bonds and stocks purchased
during the year XXX XXX XXX
6. Interest due or accrued and dividends declared and unpaid, at end of
prior year XXX XXX
7. Total investment income (line 4 minus lines 5 and 6) 0 0 0 0 0 0
6
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
EXHIBIT 2 --- UNREALIZED CAPITAL GAINS AND LOSSES
BONDS, STOCKS, MONEY MARKET MUTUAL FUNDS AND OTHER INVESTED ASSETS
1 2 3 4 5
Unrealized Capital
Market Value Gains/(Losses)
Line # Cost End of Year (Col. 4 minus Col. 3)
1. From Schedule A - Part 1 --- Bonds, Total - Current Year
2. From Schedule A - Part 1 --- Bonds, Total - Prior Year
3. Sub-total - Unrealized Capital Gains/(Losses) - Bonds, Current Year (line 2 minus line 1) XXXXX XXXXX 0
4. From Schedule A - Part 2 --- Preferred Stocks, Total - Current Year
5. From Schedule A - Part 2 --- Preferred Stocks, Total - Prior Year
6. Sub-total - Unrealized Capital Gains/(Losses) - Preferred Stocks, Current Year (line 5 minus line 4) XXXXX XXXXX 0
7. From Schedule A - Part 3 --- Common Stocks, Total - Current Year
8. From Schedule A - Part 3 --- Common Stocks, Total - Prior Year
9. Sub-total - Unrealized Capital Gains/(Losses) - Common Stocks, Current Year (line 8 minus line 7) XXXXX XXXXX 0
10. From Schedule B --- Money Market Mutual Funds, Total - Current Year
11. From Schedule B --- Money Market Mutual Funds, Total - Prior Year
12. Sub-total - Unrealized Capital Gains/(Losses) - Money Market Mutual Funds, Current Year (line 11 minus line 10) XXXXX XXXXX 0
13. From Schedule D - Part 1 --- Other Invested Assets, Total - Current Year
14. From Schedule D - Part 1 --- Other Invested Assets, Total - Prior Year
15. Sub-total - Unrealized Capital Gains/(Losses) - Other Invested Assets, Current Year (line 14 minus line 13) XXXXX XXXXX 0
16. Total - Unrealized Capital Gains/(Losses) - Bonds, Stocks, Money Market Mutual Funds, and Other Invested Assets
(sum of lines 3, 6, 9, 12 and 15) XXXXX XXXXX 0
7
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE A --- Part 1
Showing all BONDS Owned December 31 of Current Year
1 2 3 4 5 6 7 8 9
Description Interest Interest
CUSIP Rate Used Amount Due or Accrued Gross Amount
Identi- Maturity Cost to Obtain Market Value Dec. 31 of Current Year Received
fication1 Give complete description of all bonds owned Rate How Paid 2 Date (excluding accrued interest) Market Value End of Year on Bonds not in default During Year
TOTALS XXX XXX XXX 0 XXX 0 0 0
1
From entry in the previous year's Annual Statement, if owned at that time; from the purchase confirmaton (or certificate), if purchased subsequently. Leave blank for private placements.
2
Insert initial letters of months in which interest is payable.
8
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE A --- Part 2
Showing all PREFERRED STOCKS Owned December 31 of Current Year
1 2 3 4 5 6 7 8 9
Description
Rate Per
Share Used
CUSIP to Obtain Dividends
Identi- Year No. of Market Market Value Declared and Income Received
fication1 Give complete description of all preferred stocks owned Acquired Shares Cost Value End of Year Unpaid During Year
TOTALS XXX XXX 0 XXX 0 0 0
1
From entry in the previous year's Annual Statement, if owned at that time; from the purchase confirmaton (or certificate), if purchased subsequently.
SCHEDULE A --- Part 3
Showing all COMMON STOCKS Owned December 31 of Current Year
1 2 3 4 5 6 7 8 9
Description
Rate Per
Share Used
CUSIP to Obtain Dividends
Identi- Year No. of Market Market Value Declared and Income Received
fication1 Give complete description of all common stocks owned Acquired Shares Cost Value End of Year Unpaid During Year
TOTALS XXX XXX 0 XXX 0 0 0
1
From entry in the previous year's Annual Statement, if owned at that time; from the purchase confirmaton (or certificate), if purchased subsequently.
9
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE A --- Part 4
Showing all Bonds and Stocks ACQUIRED During the Year
1 2 3 4 5 6 7
Description
CUSIP Cost
Identi- No. of (Excluding Accrued Accrued Interest
fication Give complete description of each bond and stock Date Acquired1 Shares Interest and Dividends) Par Value of Bonds and Dividends Paid
BONDS
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
SUB-TOTALS -- BONDS XXX XXX 0 XXX 0
STOCKS
Preferred Stocks:
XXX
XXX
XXX
XXX
XXX
XXX
Common Stocks:
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
SUB-TOTALS -- STOCKS XXX XXX 0 XXX 0
SUB-TOTALS -- BONDS AND STOCKS XXX XXX 0 XXX 0
1
The items with reference to each issue of bonds and stocks acquired at public offerings may be totaled in one line and the word "Various" inserted in Columns 3 and 4.
10
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE A --- Part 5
Showing all Bonds and Stocks SOLD, REDEEMED or otherwise DISPOSED OF During the Year
1 2 3 4 5 6 7 8 9 10
Description
CUSIP Consideration Cost Interest on Dividends on
Identi- Disposal No. of (Excluding Accrued Par Value (Excluding Accrued Realized Capital Bonds Received Stocks Received
fication Give complete description of each bond and stock Date1 Shares Interest and Dividends) of Bonds Interest and Dividends) Gains/(Losses) During Year 2 During Year 2
BONDS
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
SUB-TOTALS -- BONDS XXX XXX 0 XXX 0 0 0 XXX
STOCKS
Preferred Stocks:
XXX
XXX
XXX
XXX
XXX
XXX
Common Stocks:
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
SUB-TOTALS -- STOCKS XXX XXX 0 XXX 0 0 XXX 0
TOTALS -- BONDS AND STOCKS XXX XXX 0 XXX 0 0 0 0
1
Segregated gift annuity funds may, at their option, summarize all bonds of the same issue called, matured or redeemed during the year and omit disposal dates.
2
Include accrued interest and dividends on bonds and stocks disposed of.
11
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE B
Showing all MONEY MARKET MUTUAL FUNDS owned December 31 of Current Year
1 2 3 4 5 6 7 8 9
Total Total
ID # or No. of Year Acquired Disposed Market Value Income Received
Symbol Description Shares Cost Acquired* During Year During Year End of Year During Year
TOTALS XXX 0 XXX 0 0 0 0
* Year acquired is on a historical basis. Report the year that the mutual fund was first acquired. (See Annual Statement Instructions for further details.)
12
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE C
CASH, MONEY MARKET AND CERTIFICATES OF DEPOSIT
As of December 31 of Current Year
1 2 3 4 5 6
Nature of account Interest Interest Accrued
Depository (Checking, CD, Money Market) Rate of Received December 31 of
Give complete description of each depository, including the full name. See note below Interest During Year Current Year Balance
OPEN ACCOUNTS
TOTALS -- OPEN ACCOUNTS XXX XXX 0 0 0
CLOSED ACCOUNTS
TOTALS -- CLOSED ACCOUNTS XXX XXX 0 XXX XXX
TOTALS -- CASH ON DEPOSIT XXX XXX 0 0 0
CASH IN SEGREGATED GIFT ANNUITY FUND'S OFFICE XXX XXX XXX XXX
Note: Money market bank accounts are to be reported in this Schedule; however, money market mutual funds (brokerage accounts) should be reported in Schedule B.
Indicate the interest rate at December 31 of the current year in Column 3.
12 cont.
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
Group each type of asset separately, i.e., real estate, etc. SCHEDULE D --- PART 1
Arrange items in each group alphabetically. Showing all OTHER INVESTED ASSETS Owned December 31 of Current Year
1 2 3 4 5 6 7 8 9
Description
Date of Most Method of Valuation
Year Market Value Recent and Name of Person/Firm Gross Income Amount of
Give complete description of asset Acquired Cost † End of Year †† Valuation Performing the Valuation Earned Expenses Encumbrances
TOTALS XXX 0 0 XXX XXX 0 0 0
† If received as a gift, the cost is the market value on date of receipt.
†† Should reflect the value of the asset that is reported on Page 2, Line 5.
13
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
Group each type of asset separately, i.e., real estate, etc. SCHEDULE D --- PART 2
Arrange items in each group alphabetically. Showing all Other Invested Assets ACQUIRED During Current Year
1 2 3 4 5 6 7 8
Description
Indicate if Asset Market Value Date of Most Method of Valuation
Date was Donated or on Date of Recent and Name of Person/Firm ID No. of Annuity or
Give complete description of each asset Acquired Purchased Cost† Acquisition Valuation Performing the Valuation Name of Annuitant††
TOTALS XXX XXX 0 0 XXX XXX
† If received as a gift, the cost is the market value on date of receipt.
†† Complete this column if the annuity issued was conditioned upon the donated asset.
13 cont.
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
Group each type of asset separately, i.e., real estate, etc. SCHEDULE D --- PART 3
Arrange items in each group alphabetically. Showing all Other Invested Assets SOLD or otherwise DISPOSED OF During Current Year
1 2 3 4 5 6 7 8 9 10 11
Market Value Date of Realized Gross Income
Date Disposal at Disposal MostRecent Consideration Gains/(Losses) Received ID No. of Annuity or
Description of asset Acquired Date Name of Purchaser Date Valuation Received on Sale During Year Expenses Name of Annuitant†
TOTALS XXX XXX XXX XXX XXX 0 0 0 0 XXX
† Complete this column if the asset sold or disposed of was a donated asset conditioned upon an annuity agreement.
14
ANNUAL STATEMENT FOR THE YEAR 2007 OF THE 0
SCHEDULE E
Showing all REINSURANCE Agreements as of December 31 of Current Year
1 2 3 4 5 6 7 8
NAIC Federal Effective Type of Amount Of Reinsurance
Company ID Date of Reinsurance Reserves Premium
Code Number Name of Reinsurer Location Agreement Agreement Ceded Paid
TOTALS XXX XXX XXX 0 0
Note: Column 7 Total should reflect the amount reported on Page 2, line 11.
14 cont.
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