Form 1041-A U.S. Information Return Trust Accumulation of Charitable

Form

1041-A

(Rev. February 2012)
Department of the Treasury
Internal Revenue Service
Name of trust

U.S. Information Return
Trust Accumulation of Charitable Amounts

OMB No. 1545-0094

For calendar year 20
Employer identification number

Name of trustee
Number, street, and room or suite no. (or P.O. box)
City or town, state, and ZIP code

Deductions

Income

Part I

Income and Deductions (See the instructions for Form 1041 or Form 5227.) If total income is $25,000 or
less, skip lines 1–8 and enter total income on line 9.

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2
3
4
5
6
7
8
9
10
11
12
13
14
15

Part II

Interest income . . . . . . . . . . . . . . . . . . . . . . . . .
Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . .
Business income or (loss) (attach Schedule C or C-EZ (Form 1040)) . . . . . . . .
Capital gain or (loss) (attach Schedule D (Form 1041)) . . . . . . . . . . . .
Rents, royalties, partnerships, other estates and trusts, etc. (attach Schedule E (Form 1040))
Farm income or (loss) (attach Schedule F (Form 1040)) . . . . . . . . . . . .
Ordinary gain or (loss) (attach Form 4797) . . . . . . . . . . . . . . . .
Other income (state type of income)
Total income (combine lines 1 through 8) . . . . . . . . . . . . . . . .
Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Charitable deduction (itemize by charitable purpose; include payee’s name and address)
Trustee fees . . . . . . . . . . . . . . . . . . . . . . . . . .
Attorney, accountant, and return preparer fees . . . . . . . . . . . . . . .
Other deductions (attach schedule) . . . . . . . . . . . . . . . . . .

Distributions of Income Set Aside for Charitable Purposes (see instructions)

16

Accumulated income set aside in prior tax years for which a deduction was claimed under section
642(c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

Income set aside in prior tax years for which a deduction was claimed under section 642(c)
and which was distributed during the current tax year (itemize by charitable purpose; include
payee’s name and address) . . . . . . . . . . . . . . . . . . . . . . .

a
b
c
d
e
18
Total (add lines 17a through 17e) . . . .
19
Balance (subtract line 18 from line 16) . .
20
Income set aside during the current tax year
642(c) (included in Part I, line 12) . . . .
Carryover (add lines 19 and 20)
. . . .
21

Part III
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23
a
b
c
d
e
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for which a
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deduction
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17a
17b
17c
17d
17e
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was claimed under section
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16

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19
20
21

Distributions of Principal for Charitable Purposes (see instructions)

Principal distributed in prior tax years for charitable purposes
. . . . . . . . . . .
Principal distributed during the current tax year for charitable purposes (itemize by charitable
purpose; include payee’s name and address) . . . . . . . . . . . . . . . . .

Total (add lines 23a through 23e)

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For Paperwork Reduction Act Notice, see the instructions.

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23a
23b
23c
23d
23e
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Cat. No. 10615B

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Form 1041-A (Rev. 2-2012)

Page 2
Balance Sheets (see instructions). If line 9, page 1, is $25,000 or less, complete only lines 38, 42,
and 45 (see instructions).

Form 1041-A (Rev. 2-2012)

Part IV

(a) Beginning-ofYear Book Value

Assets
25
26
27a
b
28a
b
29
30
31
32
33
34a
b
35
36a
b
37
38

Cash—non-interest bearing . . . . . . . . . . . . . . .
Savings and temporary cash investments . . . . . . . . . .
Accounts receivable . . . . . . . . . . . .
27a
Less: allowance for doubtful accounts . . . . . .
27b
Notes and loans receivable . . . . . . . . . .
28a
Less: allowance for doubtful accounts . . . . . .
28b
Inventories for sale or use . . . . . . . . . . . . . . .
Prepaid expenses and deferred charges
. . . . . . . . . .
Investments—U.S. and state government obligations (attach schedule)
Investments—corporate stock (attach schedule) . . . . . . . .
Investments—corporate bonds (attach schedule) . . . . . . . .
Investments—land, buildings, and equipment: basis . .
34a
Less: accumulated depreciation . . . . . . . .
34b
Investments—other (attach schedule) . . . . . . . . . . .
Land, buildings, and equipment: basis . . . . . .
36a
Less: accumulated depreciation . . . . . . . .
36b
Other assets (describe ▶
Total assets (add lines 25 through 37)
. . . . . . . . . .

39
40
41
42

Accounts payable and accrued expenses . . . . .
Mortgages and other notes payable (attach schedule) .
Other liabilities (describe ▶
Total liabilities (add lines 39 through 41) . . . . .

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42
43
44
45
46

(b) End-of-Year
Book Value

Liabilities
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Net Assets
43
44
45
46

Trust principal or corpus . . . . . . . . . . .
Undistributed income and profits . . . . . . . .
Total net assets (add lines 43 and 44) . . . . . .
Total liabilities and net assets (add lines 42 and 45) .

Signature of trustee or officer representing trustee

Print/Type preparer’s name

Firm’s name

▶

Firm’s address ▶

Preparer’s signature

▲

Paid
Preparer
Use Only

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.
▲

Sign
Here

Date

Date

Check
if
self- employed

PTIN

Firm's EIN ▶
Phone no.

Form 1041-A (Rev. 2-2012)

Form 1041-A (Rev. 2-2012)

What’s New
Future developments. The IRS has
created a page on IRS.gov for
information about Form 1041-A and its
instructions, at www.irs.gov/form1041.
Information about any future
developments affecting Form 1041-A
(such as legislation enacted after we
release these instructions) will be posted
on that page.

Reminder
Split-interest trusts as described in
section 4947(a)(2) do not file Form
1041-A. These types of trusts file Form
5227, Split-Interest Trust Information
Return, which meets the section 6034
filing requirements.

General Instructions
Section references are to the Internal
Revenue Code unless otherwise noted.

Purpose of Form
Use Form 1041-A to report the
charitable information required by
section 6034 and the related regulations.

Who Must File
The trustee must file Form 1041-A for a
trust that claims a charitable or other
deduction under section 642(c) unless
an exception applies.
Exceptions. The trustee does not file
Form 1041-A for:
• A trust that is required to distribute
currently to the beneficiaries all the
income for the tax year determined
under section 643(b) and related
regulations,
• A charitable trust described in section
4947(a)(1), or
• For tax years beginning after 2006, a
split-interest trust described in section
4947(a)(2).

When To File
File Form 1041-A by April 15 following
the close of the calendar year. If the due
date falls on a Saturday, Sunday, or
legal holiday, file on the next business
day.

Extension of Time To File
The trustee may obtain an automatic
3-month extension of time to file Form
1041-A by filing Form 8868, Application
for Extension of Time to File an Exempt
Organization Return. To receive the
automatic 3-month extension, the
trustee must file Form 8868 on or before
the original due date of Form 1041-A.
If more time is needed after the
automatic extension, file a second Form
8868 to request an additional (not
automatic) 3-month extension. This will
be granted only if you can show

Page

reasonable cause as to why the return
cannot be filed by the already extended
due date.

Amended Return
If you are filing an amended Form
1041-A, you must complete the entire
return, not just the new or corrected
information. Enter “Amended Return”
across the top of the amended Form
1041-A.
The trustee may file an amended
return at any time to change or add to
the information reported on a previously
filed return for the same period.

Where To File
File Form 1041-A at the following
address:
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201-0027

Penalties
Section 6652(c)(2) provides for separate
penalties of $10 a day, up to a maximum
of $5,000, against both the trust and the
trustee for not filing Form 1041-A on
time, unless there is reasonable cause.
The law also provides penalties for filing
a false or fraudulent return.

Rounding Off to Whole Dollars
You may show the money items on the
return and accompanying schedules as
whole-dollar amounts. To do so, drop
amounts less than 50 cents and
increase any amounts from 50 to 99
cents to the next dollar.

Attachments
If you need more space, attach separate
sheets showing the same information in
the same order as on the printed forms.
Show the totals on the printed forms.
Enter the trust’s employer
identification number (EIN) on each
sheet. Also, use sheets that are the
same size as the forms and indicate
clearly the line of the printed form to
which the information relates.

Public Inspection
See Regulations section 301.6104(b)–
1(d) for the procedures to request public
inspection of this form.

Specific Instructions
Part II. Distributions of Income
Set Aside For Charitable
Purposes
Lines 17a–17e. Provide a listing in
sufficient detail for each class of activity
for which a disbursement was made,
and a charitable deduction under section
642(c) was taken.

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Such amounts permanently set aside
must be earned from amounts
transferred to the trust before October 9,
1969.
Do not merely enter the category (that
is, religious, charitable, scientific, literary,
or educational), but also enter the
purpose 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 a
university.”

Part III. Distributions of Principal
for Charitable Purposes
Lines 23a–23e. Provide a listing in
sufficient detail, similar to the examples
provided above, for each class of
activity for amounts paid out of principal
for charitable purposes.
See the instructions for Form 1041,
U.S. Income Tax Return for Estates and
Trusts, for more information regarding
the allowance of deductions for amounts
permanently set aside for a charitable
purpose.

Part IV. Balance Sheets
Complete the balance sheets using the
accounting method the trust uses in
keeping its books and records. All filers
must complete columns (a) and (b).

Assets
When space is provided to the left of
column (a) for reporting receivables and
the related allowance for doubtful
accounts or depreciable assets and
accumulated depreciation, enter the
end-of-year figures.
Line 25. Cash—non-interest bearing.
Enter the amount of cash on deposit in
checking accounts, deposits in transit,
change funds, petty cash funds, or any
other non-interest bearing accounts. Do
not include advances to employees or
officers or refundable deposits paid to
suppliers or others.
Line 26. Savings and temporary cash
investments. Enter the total of cash in
savings or other interest-bearing
accounts and temporary cash
investments, such as money market
funds, commercial paper, certificates of
deposit, and U.S. Treasury bills or other
governmental obligations that mature in
less than 1 year.
Line 27. Accounts receivable. Enter the
total accounts receivable (reduced by
the corresponding allowance for doubtful
accounts) that arose from the sale of
goods and/or the performance of
services. Claims against vendors or
refundable deposits with suppliers or
others may be reported here if not
significant in amount. If significant in
amount, report them (with any advances
to employees or officers) on line 37,
Other assets.

Form 1041-A (Rev. 2-2012)

Line 28. Notes and loans receivable.
Enter the combined total of notes
receivable and net loans receivable
(including receivables due from officers,
directors, trustees, and other disqualified
persons). In an attached schedule, show
the following information (preferably in
columnar format):
• Borrower’s 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 of
the consideration furnished by the
lender.
Line 29. Inventories for sale or use.
Enter the amount of materials, goods,
and supplies purchased or manufactured
by the trust and held for sale or use in
some future period.
Line 30. Prepaid expenses and
deferred charges. Enter the amount of
short-term and long-term prepayments
of future expenses attributable to one or
more future accounting periods.
Examples include prepayments of rent,
insurance, and pension costs.
Lines 31, 32, and 33. Investments—
government obligations, corporate
stocks, and corporate bonds. Enter the
book value (which may be market value)
of these investments. Attach a schedule
that lists each security held at the end of
the year and shows whether the security
is listed at cost (including the value
recorded at the time of receipt in the
case of donated securities) or
end-of-year market value. Do not include
amounts on line 26. Government
obligations reported on line 31 are those
that mature in 1 year or more. Debt
securities of the U.S. government may
be reported as a single total rather than
itemized. Obligations of state and
municipal governments may also be
reported as a lump-sum total. Do not
combine U.S. government obligations
with state and municipal obligations on
the attached schedule.
Line 34. Investments—land, buildings,
and equipment. Attach a schedule of all
land, buildings, and equipment that are
held for investment purposes, such as
rental properties. List the cost or other
basis of these assets, accumulated
depreciation, and end-of-year book
value.

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Line 35. Investments—other. Enter the
amount of all other investment holdings
not reported on lines 31 through 34.
Attach a schedule describing each of
these investments held at the end of the
year. List the cost, or other basis, and
the end-of-year book value.
Line 36. Land, buildings, and
equipment. Attach a schedule of all
land, buildings, and equipment that are
not held for investment purposes, such
as the trust’s offices. List the cost or
other basis of these assets, accumulated
depreciation, and end-of-year book
value.
Line 37. Other assets. Enter the book
value of any trust assets that have not
been reported on lines 25 through 36. If
more space is needed, attach a separate
schedule with a description of the asset,
date acquired, and end-of-year book
value.

Liabilities
Line 39. Accounts payable and
accrued expenses. Enter the total
accounts payable to suppliers and
others, and accrued expenses such as
salaries payable, accrued payroll taxes,
and interest payable.
Line 40. Mortgages and other notes
payable. Attach a schedule showing, as
of the end of the year, the total amount
of all mortgages payable, and for each
nonmortgage note payable, the lender’s
name and the other information specified
in the line 28 instructions.
Line 41. Other liabilities. Enter the book
value of any trust liabilities that have not
been reported on lines 39 or 40. If more
space is needed, attach a separate
schedule with a description of the
liability and amount.

Signature
Form 1041-A must be signed by the
trustee or by an authorized
representative.
If you, as trustee (or an employee or
officer of the trust), fill in Form 1041-A,
the Paid Preparer space should be left
blank. If someone prepares this return
without charge, that person should not
sign the return.
Generally, anyone who is paid to
prepare a tax return must sign the return
and fill in the other blanks in the Paid
Preparer Use Only area of the return.

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If you have questions about whether a
preparer is required to sign the return,
please contact an IRS office.
The person signing the return as the
preparer should complete the requested
preparer information and:
• Sign it in the space provided for the
preparer’s signature. (A facsimile
signature is acceptable.)
• Give the trustee a copy of the return in
addition to the copy to be filed with the
IRS.
Paperwork Reduction Act Notice. We
ask for the information on this form to
carry out the Internal Revenue laws of
the United States. You are required to
give us the information. We need it to
ensure that you are complying with
these laws and to allow us to figure and
collect the right amount of tax.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records
relating to a form or its instructions must
be retained as long as their contents
may become material in the
administration of any Internal Revenue
law. Generally, tax returns and return
information are confidential, as required
by Code section 6103.
The time needed to complete and file
this form will vary depending on
individual circumstances. The estimated
average time is:
Recordkeeping . . .
Learning about the
law or the form . . .
Preparing the form .
Copying, assembling,
and sending the
form to the IRS . . .

24 hr., 52 min.
. 2 hr., 37 min.
. 7 hr., 48 min.
. 1 hr., 20 min.

If you have comments concerning the
accuracy of these time estimates or
suggestions for making this form
simpler, we would be happy to hear
from you. You can write to the Tax
Products Coordinating Committee,
SE:W:CAR:MP:T:M:S, IR-6526, 1111
Constitution Ave. NW, Washington, DC
20224. Do not send the tax form to this
address. Instead, see Where To File
earlier.