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                                   120 Broadway                                         Inspection
 (remainder trusts use CHAR001-RT,                                     New York, NY 10271
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 (2010)