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                                                        Charitable Activities Section                                            For Accounting Periods Beginning in:

     For Split-Interest Trusts
                                                       Oregon Department of Justice
                                                  1515 SW 5th Avenue, Suite 410
                                                  Portland, OR 97201-5451
                                                                                                VOICE (971) 673-1880
                                                                                                TDD   (503) 378-5938             2005
                                                  E-Mail: FAX (971) 673-1882
                                                  Web site:
Section I.           General Information
1.                                                                                 Cross Through Incorrect Items and Correct Here:
                                                                                   (See instructions for change of name or accounting period.)

                                                                                   Registration #:

                                                                                   Organization Name:


                                                                                   City, State, Zip:

                                                                                   Phone:                                 Fax:                             Amended
                                                                                   Period Beginning:        /    /        Period Ending:        /    /

2.     Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor’s report, financial statements,
                                                                                                                                                         Yes      No
       accompanying notes and any schedules presented as supplementary information to the basic financial statements.

3.     Has the trust or any officer, trustee, or executive personnel of the trust ever been involved in a voluntary agreement with any
       district attorney or attorney general or a legal action in any court regarding the trust’s solicitation, administration, or management            Yes      No
       practices? If yes, attach copies of the agreement and a written explanation.

4.     During this reporting period, did the trust amend any trust documents OR did the trust receive a determination letter from the
       Internal Revenue Service indicating a new or amended tax-exempt status? If yes, attach a copy of the amended document or                          Yes      No
                                                                                                                                                         Yes      No
5.     Is the trust ceasing operations and is this the final report?   (If yes, see instructions.)

6.     Provide contact information for the person responsible for retaining the trust’s records.

                        Name                             Position                 Phone                                  Mailing Address

7.     List of Officers, Directors, Trustees and Key Employees – List each person who held one of these positions at any time during the year even if they did
       not receive any compensation from the organization. Attach additional sheets if necessary. If an IRS form is attached that includes substantially the
       same information, the phrase “See IRS Form” may be entered in lieu of completing this section.

                       (A) Name, daytime phone number                            (B) Title &                 (C)         (D) Contributions       (E) Expense
                              & mailing address                               average weekly           Compensation       to benefit plans      account & other
                                                                              hours devoted to          (If not paid,        & deferred           allowances
                                                                                  position                enter $0)        compensation
       Name:        __________________
       Address:     __________________
                    (  )
       Name:        __________________
       Address:     __________________
                    (  )
       Name:        __________________
       Address:     __________________
                    (  )

                                                            Form Continued on Reverse Side
Section II.          Fee Calculation
8.    Charitable Distribution ...........................................................................................................         8.
      (Line 12 on Form 1041-A.)

9.    Charitable Distribution Fee ..................................................................................................................................................        9.
      (See chart below. Minimum fee is $10.)
            Amount on Line 8          Charitable Distribution Fee
      $0            -    $24,999                 $10
      $25,000       -    $49,999                 $25
      $50,000       -    $99,999                 $45
      $100,000      -   $249,999                 $75
      $250,000      -   $499,999                $100
      $500,000      -   $749,999                $135
      $750,000      -   $999,999                $170
      $1,000,000 or         more                $200

10.   Net Assets at the End of the Reporting Period ........................................................................                      10.
      (Line 45b on Form 1041-A or Line 46b on Form 5227.)

11.   Net Assets Fee ....................................................................................................................................................................   11.
      (Line 10 multiplied by .0001. If the fee is less than $5, write $0. Not to exceed $1,000. Round cents to the nearest whole dollar.)

12.   Delinquency Penalty ...........................................................................................................................................................       12.
      (If report is submitted after the due date, the delinquency penalty is $20.)

13.   Total Amount Due ...............................................................................................................................................................      13.
      (Add Lines 9, 11, and 12. Make check payable to the Oregon Department of Justice.)

14.   Attach a copy of the trust’s federal tax returns and all supporting schedules and attachments.

Please                Under penalties of perjury, I declare that I have examined this return, including all accompanying forms, schedules, and attachments, and to
                      the best of my knowledge and belief, it is true, correct, and complete.
                            _______________________________________                                                 _____________________                                  _____________________
                            Signature of officer                                                                    Date                                                   Title
                            _______________________________________                                                 _____________________                                  _____________________
Use Only
                            Preparer’s signature                                                                    Date                                                   Phone

                            _______________________________________                                                 ___________________________________________________
                            Preparer’s name                                                                         Address
Charitable Activities Section, Oregon Department of Justice

2005 Form CT-12S Instructions

                                                       The Charitable Activities Section does not use
General                                                the postmark date to determine whether an
                                                       organization has filed timely. Instead, filings are
                                                                                                             Important Note - An extension request filed
                                                                                                             with the IRS or the Oregon Department of
Instructions                                           considered to have been made timely if they are
                                                       physically received 5 or less business days after
                                                                                                             Revenue does NOT act as an extension with the
                                                                                                             Charitable Activities Section unless a copy is
                                                       the due date. All filings received more than 5        submitted to the Charitable Activities Section by
                                                       days after the due date will be assessed a $20        the due date.
Purpose                                                late charge.
Oregon law charges the Attorney General with
the duty and responsibility to represent the                                                                 Record Keeping
public’s interest in connection with assets held       Extensions for Filing and                             Please retain a copy of this report and all
for charitable purposes. The Attorney General          Paying Fees                                           supporting documentation for at least five years
                                                                                                             after the due date.
carries out this responsibility by requiring
organizations holding such assets to register and      A trust may apply for an extension of time to
file periodic financial reports.                       file. Extension requests must be received on or
                                                       before the due date of the report to avoid a          Rounding and Blank Lines
Once submitted, this Form and all attachments          delinquency penalty. The Charitable Activities        Round all amounts on the report to the nearest
become a part of the public record. Any                Section grants initial extension requests for up to   whole dollar. Drop amounts under 50 cents and
interested person may examine or obtain a copy         90 days. An additional extension may be               increase amounts from 50 to 99 cents to the next
of an annual report of a charitable organization       requested, if necessary, for a maximum total          whole dollar.
by contacting the Charitable Activities Section.       extension period of 180 days. An extension to
                                                       file is also an extension to pay any associated       Do not leave any line blank. Write “N/A,” “$0,”
                                                       fees. Therefore, estimated payments should not        or “none” where appropriate.
Who Must File                                          be included with extension requests.
All corporations and trusts registered with the
Charitable Activities Section of the Oregon            Extensions may be requested through the               Changes This Year
Department of Justice must annually file Form          Department     of    Justice    web     site    at    The Charitable Activities Section’s policy on
CT-12, CT-12F, or CT-12S unless the Attorney        granting extensions of time to file has changed.
General has specifically exempted the                  nd.shtml. Follow the instructions carefully to        The maximum initial extension period that a
organization from the reporting requirements.          ensure that the Charitable Activities Section         trust may request has been reduced from 180
                                                       receives your request. Please contact our office      days to 90 days. See the preceding section of
                                                       if you have any questions about the on-line           these instructions for complete information on
What Form to File                                      extension process or are experiencing difficulties    how to apply for an extension.
File Form CT-12 unless the organization is a           with your on-line request.
corporation organized under the laws of a state
other than Oregon or the organization is a split-      The trust may also submit a written extension         How to Contact the
                                                       request so long as the Charitable Activities
interest trust with non-charitable beneficiaries.
                                                       Section receives the request on or before the due
                                                                                                             Charitable Activities
File Form CT-12F if the organization is a              date of the report. The trust should include the      Section
corporation organized under the laws of a state        reason why additional time is necessary in the        To obtain blank forms, technical assistance or
other than Oregon. The Charitable Activities           written request.       Sending the Charitable         information about a charitable organization,
Section does not accept multi-state annual report      Activities Section a copy of the trust’s federal      contact the Charitable Activities Section or visit
forms in lieu of a completed Form CT-12F.              extension request on either Form 2758 or Form         our web site at:
                                                       8868 is also sufficient to obtain an extension for
File Form CT-12S if the organization is a split-       the period covered by the Form. The trust’s 4 or          Charitable Activities Section
interest trust that holds assets for the benefit of    5-digit registration number should be noted on            Oregon Department of Justice
both charitable and non-charitable beneficiaries.      the top of all extension requests. If you would           1515 SW 5th Ave, Suite 410
                                                       like acknowledgement that your extension                  Portland, OR 97201-5451
If the organization does not fit within any of the     request has been received, you should enclose an          Phone: (971)673-1880
above categories, file Form CT-12.                     additional copy of the request and a self-                TDD: (503)378-5938
                                                       addressed, stamped envelope.                              Fax:    (971)673-1882
Due Date                                               The Charitable Activities Section will not                Web site:
The Form, all required attachments and                 provide formal notice that the trust’s extension
schedules, and payment of fees are due in the          request has been approved. Instead, the trust
Charitable Activities Section’s office no later        should assume that its extension request has          Where to File
than 4 months and 15 days after the end of the         been granted unless you hear otherwise from our       Send completed Forms and any corresponding
organization’s fiscal year. If the due date falls on   office. In the event your request is denied, to       payment of fees to the above address. The
a weekend or legal holiday, the due date is the        avoid a delinquency penalty, the annual report        Charitable Activities Section does not accept the
next business day.                                     must be submitted by the later of the due date or     electronic filing of Forms.
                                                       within 10 days after the trust receives notice of
                                                       denial of the requested extension.
                                                      2.    Independent Audit                                7. Officers, Directors,
                                                      Check yes if the trust had an independent audit        Trustees, and Other Key
                                                      of its financial records performed by a certified      Employees
Line Instructions                                     public accountant. Attach a copy of the
                                                      auditor’s report, the financial statements, the        List each person who was an officer, director,
                                                      accompanying notes and any schedules                   trustee, or key employee (defined below) of the
                                                                                                             trust at any time during the year even if they did
                Section I.                            presented as supplementary information to
                                                                                                             not receive any compensation from the trust.
                                                      the basic financial statements.
                                                                                                             Enter a zero in columns (C), (D), or (E) if no
                                                                                                             compensation, contributions, expenses and other
      General Information                             If instead of an audit, the trust had its financial
                                                                                                             allowances were paid during the reporting year,
                                                      records either reviewed or compiled by a
                                                      certified public accountant there is no                or deferred for payment to a future accounting
                                                                                                             period. Give the daytime phone number and
1.   Missing or Incorrect
                                                      requirement to submit a copy of the related
                                                      reports. However, the Charitable Activities            preferred mailing address at which officers, etc.,
Information                                           Section encourages voluntary submission of             want the Department to contact them. Use an
                                                      review and compilation reports which will be           attachment if there are more persons to list than
The Charitable Activities Section sends a Form                                                               there are lines available.
preprinted with name, address contact                 maintained in our files that are available for
information and registration number to all            public inspection.
                                                                                                             Show all forms of cash and noncash
registered trusts. If the trust has received one of                                                          compensation received by each listed officer,
these preprinted Forms, provide any missing or
corrected information. If the organization is         3.    Disclosure Information                           etc., whether paid currently or deferred.

completing a blank Form, provide requested            Check yes if the trust or any person involved          A failure to fully complete this part can subject
information in this section.                          with the trust has entered into any agreement          the trust to penalties for filing an incomplete
                                                      such as an assurance of voluntary compliance or        Form.
Name Changes                                          discontinuance with any district attorney or
                                                      attorney general; or if any present officer,           The trust may also provide an attachment to
If applicable, write the trust’s new legal name.      executive personnel, director, or trustee has ever
Attach a copy of the trust document that changed                                                             explain the entire compensation package for any
                                                      been enjoined from soliciting contributions, or        person listed in this part.
the trust name.                                       has been found (or proceedings pending) to have
                                                      been engaged in unlawful practices in the              If an IRS form is attached that includes
Address and Phone Number                              solicitation of contributions or administration of     substantially the same information, the phrase
                                                      charitable assets. Attach copies of agreements         “See IRS Form” may be entered in lieu of
Changes                                               and/or explanations.                                   completing this section only if the daytime
If applicable, write the new address where mail
                                                                                                             phone number and preferred mailing address of
for the trust should be directed in the future. If
applicable, write the new daytime phone number
and fax machine number for the trust.
                                                      4. Amendments to Trust
                                                                                                             the officers, etc. are provided either in this
                                                                                                             section or on the attached IRS form.
                                                                                                             A "key employee" is any person having
                                                      Check yes if during the reporting period the trust
Accounting Year Changes                               amended the documents that created the trust or
                                                                                                             responsibilities or powers similar to those of
If applicable, write the trust’s new or short                                                                officers, directors, or trustees. The term includes
                                                      if the IRS issued a tax-exempt status ruling for
reporting period. Preprinted forms will note the                                                             the chief management and administrative
                                                      the trust.
subsequent accounting period to that reported in                                                             officials of a trust (such as executive director or
the prior year. If the trust has changed its fiscal                                                          chancellor) but does not include the heads of
                                                      Important Note—Attach signed and dated
year or is filing a final report for a period less                                                           separate departments or smaller units within a
                                                      copies of amended trust documents and/or IRS
than 12 months, the shortened period covered by                                                              trust.
                                                      determination letters.
the report must be noted here.
                                                                                                             A chief financial officer and the officer in charge
Important Note—If the trust is filing a final
report, see the instructions for line 5 for
                                                      5.    Final Report                                     of administration or program operations are both
                                                                                                             key employees if they have the authority to
dissolution requirements.                             Check yes if this is the final report for the trust.   control the trust's activities, it's finances, or both.
                                                                                                             The "heads of separate departments" reference
Important Note—If the trust is filing a               The trust should contact the Charitable Activities     applies to persons such as the head of the
shortened report due to a change in fiscal year,      Section     for   specific     instructions   and      radiology department or coronary care unit of a
see the instructions for line 11 for calculation of   requirements relating to closing procedures.           hospital or the head of the chemistry or history
prorated Net Assets fee.                                                                                     or English department at a college. These
                                                      A final report must reflect the financial              persons are managers within their specific areas
                                                      transactions of the trust from the day after the       but not for the trust as a whole and, therefore, are
Amended Reports                                       close of its last accounting period to the date of     not key employees.
If amending previously submitted information          the disposition of all remaining assets, and it
for the same accounting period, check the             must be filed within four months and 15 days                            Column (C)
amended report box. Either complete a blank           after such termination.                                For each person listed, report salary, fees,
form that includes the amended information or                                                                bonuses and severance payments paid. Include
provide a copy of the previously submitted form                                                              payments of amounts reported or reportable as
that clearly shows what information is being          6.    Who Keeps the Books?                             deferred compensation in any prior year.
amended. Submit any additional fee due with the       Indicate the person to be contacted if the trust's
amended report. The Charitable Activities             books need to be accessed for information or                            Column (D)
Section will mail any refund within 60 days from      review. Either a business or personal phone            Include in this column all forms of deferred
the receipt of an amended report. A $25 refund        number and mailing address are acceptable.             compensation and future severance payments
processing fee may be assessed.                                                                              (whether or not funded; whether or not vested;
                                                                                                             and whether or not the deferred compensation
plan is a qualified plan under section 401(a)).         1,000,000    or         more            200          11 should be prorated by the number of months
Include also payments to welfare benefit plans                                                               covered by the report. To determine the prorated
on behalf of the officers, etc. Such plans provide     The maximum amount subject to the charitable          amount, divide the amount determined above by
benefits such as medical, dental, life insurance,      distribution fee is $1,000,000. The maximum           12 and multiply by the number of months
severance pay, disability, etc. Reasonable             charitable distribution fee is $200. The minimum      covered by the short report. No similar proration
estimates may be used if precise cost figures are      charitable distribution fee is $10.                   should be made if the short report is due to the
not readily available.                                                                                       initial or final reporting period.

Unless the amounts were reported in column (C),        10.  Net Assets at the End of
report as deferred compensation in column (D),         the Reporting Period                                  12.      Delinquency Penalty
salaries and other compensation earned during
                                                       The Charitable Activities Section has adopted         If the report is not filed or the fee is not paid by
the period covered by the Form, but not yet paid
                                                       the definition for “Net Assets” used by the           the due date (or the extended due date), an initial
by the date the trust files its Form.
                                                       Internal Revenue Service. If the trust completed      penalty charge in the amount of $20 will be due.
                                                       one of the following IRS Forms for this               Additional penalties will be assessed until
                    Column (E)
                                                       reporting period, the Net Assets figure should        compliance occurs.
Enter both taxable and nontaxable fringe benefits
(other than de minimis fringe benefits described       come from the line number listed:
                                                              IRS Form 1041-A, Part IV, line 45b
in section 132(3) of the Internal Revenue Code).
Include expense allowances or reimbursements                  IRS Form 5227, Part IV, line 46b              13.      Total Amount Due
that the recipients must report as income on their                                                           Add lines 9, 11, and 12. This is the total amount
separate income tax returns. Examples include          If the trust was not required to complete one of      due. Make check or money order payable to the
amounts for which the recipient did not account        these IRS Forms a summary of what constitutes         “Oregon Department of Justice”. Do not send
to the trust or allowances that were more than         Net Assets is provided within these instructions.     cash. Mail payment together with the report to:
the payee spent on serving the trust. Include          A more detailed definition can be found in the
payments       made      under     indemnification     IRS instructions for the listed Forms.                      Charitable Activities Section
arrangements, the value of the personal use of                                                                     Oregon Department of Justice
                                                       Net Assets refer to the trust’s assets minus                1515 SW 5th Avenue, Suite 410
housing, automobiles, or other assets owned or
                                                       liabilities.                                                Portland, Oregon 97201-5451
leased by the trust (or provided for the trust’s use
without charge), as well as any other taxable and      “Assets” are items of value to the trust, such as
nontaxable fringe benefits.                            cash, receivables less any allowance for doubtful     Important Note—Indicate on the check the
                                                       accounts,     inventory,     prepaid   expenses,      trust’s 4 or 5-digit Oregon Department of Justice
                                                       investments, land, buildings & equipment less         registration number. The registration number is
                Section II.                            any accumulated depreciation if the trust records     located on line 1 of the preprinted Form CT-12S
                                                       depreciation.                                         or can be obtained by contacting the Charitable
                                                                                                             Activities Section.
          Fee Calculation
                                                       “Liabilities” are the amount of debts and
                                                       obligations owed by the trust, such as accounts
8.    Charitable Distribution                          payable, accrued expenses, deferred revenue,          14.  IRS Forms, Schedules,
                                                       loans, and mortgages.                                 and Attachments
The charitable distribution represents the total
amount paid to charitable organizations. If an                                                               All trusts must attach a complete copy of all
                                                       Important Note— If the trust disposed of all or
IRS Form 1041-A was filed, this amount should                                                                Forms, supporting schedules, and attachments
                                                       substantially all of the trust’s assets during this
come from Line 12. If no IRS Form 1041-A was                                                                 filed with the IRS. This may include IRS Form
                                                       reporting period, attach a letter listing a
filed, the amount will need to be calculated.                                                                1041-A and/or IRS Form 5227.
                                                       description of the asset and the name, address,
                                                       phone number, and contact person of each entity

9.    Charitable Distribution Fee
                                                       which received the trust’s assets, unless the                   Signature Block
                                                       assets were transferred in the usual and regular
                                                                                                             To make the return complete, a receiver, trustee,
Use the charitable distribution figure from line 8     course of business.
                                                                                                             or assignee must sign any return he or she files
to calculate the charitable distribution fee                                                                 for the trust. Signature stamps and labels are not
according to the following schedule.
                                                       11.      Net Assets Fee                               acceptable.
      Charitable Distribution Fee Schedule             Multiply the amount subject to a Net Assets fee       In the paid preparer’s information section,
                                                       from line 10 by .0001 and enter this figure on        include the name, daytime phone number, and
       Amount on Line 8           Distribution Fee     line 11. Round to the nearest whole dollar. If the    address of any person who was paid by the trust
$         0   -    $ 24,999             $ 10           result is less than $5 enter $0. If the result is     to complete this report.
     25,000   -       49,999               25          more than $1,000 enter $1,000.
     50,000   -       99,999               45
    100,000   -      249,999               75          Important Note—If the trust is filing a short
    250,000   -      499,999             100           report of less than one year due to a change in
    500,000   -      749,999             135           accounting periods, the amount entered on line
    750,000   -      999,999             170

            Contact the Following Agencies for Assistance
                                                       Portland, Oregon 97201-5451
    Charitable Activities                              phone: (971)673-1880
          Section                                      TDD:      (503)378-5938
                                                       fax:      (971)673-1882                                      Questions about annual reports for
Oregon Department of Justice
                                                       e-mail:                 charitable organizations-Forms CT-12,
1515 SW 5th Avenue, Suite 410
                                                       web site:                          CT-12F, and CT-12S
        Registration of charitable corporations or         1024, Application for Recognition of             Revocation of Dissolution
         trusts                                              Exemption Under §501(a)
        Merging nonprofit organizations                    1041, U.S. Income Tax Return for           Publications
        Dissolving nonprofit organizations                  Estates and Trusts
        Reporting illegal activity by nonprofit            1041-A, U.S. Information Return - Trust          Oregon Business Guide
         organizations                                       Accumulation of Charitable Amounts
        Serving as a board member of a nonprofit           1128, Application to Adopt, Change, or
         organization                                        Retain a Tax Year
        Information about charitable                       2758, Application for Extension of Time          Oregon Department
         organizations and copies of annual                  To File Certain Excise, Income,                     of Revenue
         reports                                             Information, and Other Returns
                                                            4720, Return of Certain Excise Taxes on    Revenue Building
                                                             Charities and Other Persons                955 Center St. NE
                                                            5227, Split-Interest Trust Return          Salem, OR 97301
        RF-C, Registration Form for Charitable             5768, Election/Revocation of Election by   phone: (503)378-4988 and (800)356-4222
         Corporations                                        an Eligible Section 501(c)(3)              TTY:     (503) 945-8617 and (800)886-7204
        RF-T, Registration Form for Trusts                  Organization to Make Expenditures to       web site:
        CT-12, Annual Report Form for                       Influence Legislation
         Domestic Operating Charities                       8822, Change of Address                    Issues
        CT-12F, Annual Report Form for                     8868, Application for Extension of Time
         Foreign Charities                                   to File an Exempt Organization Return                  State taxation and filing
        CT-12S, Annual Report Form for                                                                             requirements
         Domestic Trusts with Non-Charitable
         Beneficiaries                                Publications
        Closing Form                                   
                                                                                                                    20, Oregon Corporation Excise Tax
                                                            Pub. 526, Charitable Contributions
Publications                                                Pub. 538, Accounting Periods and
                                                                                                                    41, Oregon Fiduciary Income Tax
                                                                                                                   Return
         Oregon Wise Giving Guide                           Pub. 557, Tax-Exempt Status for Your
        Oregon Business Giving Guide                        Organization
        A Guide to Non-Profit Board Service in             Pub. 578, Tax Information for Private
         Oregon                                              Foundations and Foundation Managers                 State of Oregon
                                                            Pub. 583, Starting a Business and
Oregon Revised Statutes                                      Keeping Records                            web site:
                                                            Pub. 598, Tax on Unrelated Business
        Chapter #65, Nonprofit Corporations
                                                             Income of Exempt Organizations
        Chapter #128, Trusts; Charitable
                                                            Pub. 3079, Gaming Publication for Tax-
                                                             Exempt Organizations
        Chapter #464, Games
        Chapter #646, Trade Practices &
         Antitrust Regulations                              Corporation Division
Oregon Administrative Rules                           Public Service Building
        Chapter #137-010-005 et seq.                 255 Capitol Street NE, Suite 151
                                                      Salem, OR 97310-1327
                                                      phone: (503)986-2200
  Internal Revenue Service                            TTY:      (503)986-2328
                                                      fax:      (503)378-4381
                                                      web site:
phone:     (877)829-5500                    
TTY:       (800)829-4059
web site:
Issues                                                      Forming a new corporation
                                                            Obtaining state and federal tax
        Obtaining federal tax-exempt status
                                                             identification numbers
        Completing federal tax forms
                                                            Merging nonprofit corporations
                                                            Dissolving nonprofit corporations
Forms                                                       Amending articles of incorporation
        990, Return of Organization Exempt                 Obtaining copies of filed articles of
         From Income Tax                                     incorporation and amendments
        990-EZ, Short Form - Return of
         Organization Exempt From Income Tax          Forms
        Schedule A, for Form 990 and 990-EZ
                                                            Articles of Incorporation
        990-PF, Return of Private Foundation
                                                            Assumed Business Name Registration
        990-T, Exempt Organization Business
         Income Tax Return                                  Articles of Amendment
        1023, Application for Recognition of               Restated Articles
         Exemption Under §501(c)(3)                         Articles of Dissolution

Description: This is an example of irs extension form. This document is useful for conducting irs extension form.