Registration Statement for Charitable Lead Trusts 
Form CHAR001-LT                          New York State Department of Law (Office of the Attorney General) 
                                                      Charities Bureau - Registration Section                       Open to Public
For Registration of Lead Trusts Only                                 28 Liberty Street                                 Inspection
 (remainder trusts use CHAR001-RT,                           New York, NY 10005
charitable organizations use CHAR410,
estates submit Notice of Probate)                            www.charitiesnys.com

Part A - Identification of Registrant
1. Full Name of Trust                                                                  7. Full Name of Grantor/Testator

2. c/o Name (individual, law firm, etc.)                                               8. Fed. employer ID no. (EIN)

3. Mailing address (Number and street)                                 Room/suite      9. Date of Trust and any Amendments/Codicils

City or town, state or country and ZIP+4                                               10. Type of Trust:
                                                                                       Inter vivos ................................    G
                                                                                       Testamentary .............................      G
4. Phone              5. Fax                 6. Email address                          11. Fiscal Year End (mm/dd)

Part B - Identification of Trustees (list information for each trustee)
Name                                     Address

Part C.1. - Identification of Remainder Beneficiaries (list information for each remainder beneficiary)
Name                                     Date of Death (if applicable) Description of Interest

Part C.2. - Identification of Charitable Lead Beneficiaries (list information for each charitable lead beneficiary)
Organization Name                            Federal EIN    Lead Interest End Date Description of Interest

Part D - Attachments - All Documents Required
Attach a copy of the trust instrument to this Registration Statement.

Part E - Certification

Signature                                    Printed Name                   Title                                  Date

                                                                                                                    Form CHAR001-LT (2018)