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                                                                                                            Mail completed form to: 
    
                                                                                                            NH Attorney General’s Office 
                                                                                                            Attn: Charitable Trusts Unit 
                                                                                                            One Granite Place South 
                                                                                                            Concord, NH 03301 

  FORM NHCT-12 
  ANNUAL REPORT 
  *Instructions for the form are at the following web link: 
   
  https://www.doj.nh.gov/charitable-trusts/documents/nhct12-instructions.pdf  
    
This form must be accompanied by a payment in the amount of $75.00, unless previously paid with Form 
   NHCT-14 for the reporting period. Checks must be made payable to “State of New Hampshire.” 
    
 Report is for fiscal year end date (MM/DD/YYYY): _______________________________ 
  
 Is this a consolidated report for multiple years because the entity was granted a suspension of its annual 
 requirement? 
   □ Yes (if yes, state the beginning date of the consolidated report) __________________________________ 
   □ No 
 
CHARITABLE TRUST  NFORMATIONI                                        
    
                                                                                             NH Charitable Trusts Unit Registration No. 
  Entity Name                                                      □Check here if new name 

                                                                                             City           State                       Zip 
  Mailing Address                                               □Check here if new address 

  Entity Website Address 

CONTACT INFORMATION          
 Contact Name 

 Contact Address                                                                             City           State                       Zip 

 Contact Telephone Number 

 Contact Email Address 

         NHCT-12 (May 2024)                                               www.doj.nh.gov/charitable-trusts/ charitabletrustsunit@doj.nh.gov 
                                                                                                                                             
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CHARITABLE TRUST UESTIONNAIREQ

1. Did the entity submit a Form NHCT-14 Application for Extension of Time to File Annual Report
with payment of the $75.00 filing fee required by RSA 7:28-a, II?
□ Yes
□ No

2. Which of the following IRS forms did the entity file for the reporting period?
□ IRS Form 990-N → Submit Schedule A. Do not submit IRS Form 990-N.
□ IRS Form 990-EZ → Submit IRS Form 990-EZ.
□ IRS Form 990-PF → Submit IRS Form 990-PF. Go to Question 4.
□ IRS Form 990 → Submit IRS Form 990.
□ IRS Form 5227 → Submit IRS Form 5227.
□ IRS Form 1041 → Submit IRS Form 1041 and Schedule A.
Submit Schedule A and provide an explanation why the
□ No IRS Form →
entity did not file any IRS Form for the reporting period.

3. Is the entity a New Hampshire nonprofit corporation (RSA 292) or otherwise headquartered in New
Hampshire? (Skip this question if the entity files IRS Form 990-PF)
□ Yes → Submit Schedule C and continue to Question 4.
□ No → Go to Question 6.

4. What was the entity’s revenue for the reporting period?
□ Less than $500,000 → Go to Question 5.
Submit the entity’s latest financial statement prepared in
□ $500,000 or more but less
→ accordance with generally accepted accounting principles
than $2,000,000
(GAAP).
Submit the entity’s latest audited financial statement prepared
□ $2,000,000 or more → in accordance with generally accepted accounting principles
(GAAP).

5. Does the entity file an accounting with the New Hampshire Circuit Court—Probate Division?
□ Yes → Submit the accounting filed with the Probate Division.
□ No → Go to Question 6.

6. Does the entity issue/offer Charitable Gift Annuities to New Hampshire citizens?
□ Yes → Submit Schedule D.
□ No → Go to Question 5.

7. Is this the entity’s final report (i.e., is your entity dissolving or withdrawing from registration)?
□ Yes → Submit Schedule E.
□ No → Go to Question 5.

8. All charitable trusts are required to submit a governing board list. (Complete Schedule B)

NHCT-12 (May 2024) www.doj.nh.gov/charitable-trusts/ charitabletrustsunit@doj.nh.gov

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FORMNHCT-12:  CHEDULES                  A                                              Year-end: __________________ 

FINANCIAL REPORT        

 A. Employer Identification Number (EIN)  ____________________________________ 
  
 B. IRS Federal Tax Exemption Status      *select one 
              
    □ 501 (c)(3)     □ 501 (c) (_________)            □ Not tax exempt                  
       
      Check Here if: □ 1023 or 1023-EZ application is pending review with the IRS. 

      Check Here If:  □Part of IRS group tax exemption. 
       
      If part of an IRS group tax exemption, state the name of the central organization: 
      ___________________________________________________________________________________ 
       
Part I: Statement of Program Service Accomplishments 
 
 C. Describe the entity’s primary charitable purpose. 
 (If the entity is a New Hampshire corporation, it must have one or more specific charitable purposes, which must be reflected in the 
 organization’s Articles of Agreement.) 
  
 ___________________________________________________________________________________

 _________________________________________________________________________________ 

 D. Describe briefly each of the entity’s largest programs (measured by expenses) and the services provided. 
    (These program expense amounts must be included within the expense category in Part II, lines F8 through F16.) 
              
                             Description of Program                                              Program Expenses 
                                                                                         
        NHCT-12 (May 2024)                           www.doj.nh.gov/charitable-trusts/           charitabletrustsunit@doj.nh.gov 
                                                                                                                                       
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Part II: Revenue and Expenses 

 E.   Revenue 
      1.   Donations and grants received (not fundraising events)           $ __________________ 
      2.   Program service revenue (received in exchange for services)      $ __________________ 
      3.   Membership fees                                                  $ __________________ 
      4.   Interest and dividends                                           $ __________________ 
      5.   Gross receipts from special fundraising events and activities    $ __________________ 
      6.   Other revenue                                                    $ __________________ 

      7. Total revenue (add lines 1 through 6)                              $ __________________ 
  
  F.  Expenses 
      8. Cash and benefit amounts paid to unrelated persons or groups       $ __________________ 
      9. Cash and benefit amounts paid to or for directors or members       $ __________________ 
      10. Compensation of officers, directors, and key employees            $ __________________ 
      11. Other salaries and wages                                          $ __________________ 
      12. Payroll taxes and employee benefits                               $ __________________ 
      13. Professional fees and other payments to independent contractors   $ __________________ 
      14. Occupancy, rent, utilities, and insurance                         $ __________________ 
      15. Printing, publications, postage, office supplies, and IT          $ __________________ 
      16. Other expenses                                                    $ __________________ 

      17. Total expenses (add lines 8 through 16)                           $ __________________ 

  G. Net income (or loss) (subtract line 17 from line 7)                    $__________________ 

      NHCT-12 (May 2024)             www.doj.nh.gov/charitable-trusts/      charitabletrustsunit@doj.nh.gov 
                                                                                                
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Part III: Balance Sheet 

  H.    Assets 
      1. Cash, savings and checking accounts, investments                          $ ________________ 
      2. Real estate less any depreciation                                         $ ________________ 
      3. Other property and equipment less any depreciation                        $ ________________ 
      4. Pledges, grants, accounts receivable                                      $ ________________ 
      5. Other assets                                                              $ ________________ 

      6.  Total assets (add lines 1 through 5)                                     $ ________________ 
 
  I.    Liabilities 
      7. Accounts payable                                                          $ __________________ 
      8. Loans, grants payable                                                     $ __________________ 
      9. Other Liabilities                                                         $ __________________ 

      10. Total liabilities (add lines 7 through 9)                                $ __________________ 
 
 J.  Fund Balance/Net worth (subtract line 10 from line 6)                         $ __________________ 
 
 K.  Amount of fund balance that is donor-restricted                               $ __________________ 
 
 L.  Fund balance/net worth at prior year end (prior year’s Line J)                $ __________________ 
 
 M. Change in fund balance (subtract line L from line J)                           $ __________________ 
 
 N. Variance (subtract line M from line G)                                         $ __________________ 
      
 O. If line N is not $0, explain reason for variance. 
   
      NHCT-12 (May 2024)                        www.doj.nh.gov/charitable-trusts/  charitabletrustsunit@doj.nh.gov 
                                                                                                       
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FORM NHCT-12: S  CHEDULE B 
                                                                   1
                           GOVERNING BOARD  ISTL                       

Entity Name: _________________________________________                Year-end: ____________________ 

For entities based in New Hampshire, provide all the information set forth in the chart below. 

For entities not based in New Hampshire, complete the names and titles of the members of the governing board on 
this Schedule B, or submit a board list containing the names and titles of the governing board. 

                                                                                                Av. Hours     Compensation 
                                                         Daytime                                per week      and benefits 
                                                         Telephone                              devoted to    paid  2
 Name        Title        Home Address                   Number       Email Address             position      (enter 0 if none) 
                                                                                                               
  1 The entity is permitted to submit its own spreadsheet in lieu of Form NHCT-12: Schedule B, as long as the 
  spreadsheet contains the information requested herein. 
  2 Include any compensation paid by the entity to the individual, whether as a board member, employee, or independent 
  contractor. Do not include amounts the entity pays for reimbursement of reasonable expenses as a director, officer, or 
  trustee. 
       NHCT-12 (May 2024)   www.doj.nh.gov/charitable-trusts/                       charitabletrustsunit@doj.nh.gov 
                                                                                                                          
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FORM NHCT-12: S CHEDULE C Year-end: _________________

CONFLICT OF INTEREST AND OVERNANCE G EPORTR
Required for all New Hampshire-based charitable entities, except those that file an IRS Form 990-PF.

1. Has there been a change made to the entity’s conflict of interest and/or pecuniary benefit
transaction policies this year?
□ Yes □ No (If yes, attach the new policy)

2. Did any officer, director, trustee, or member of his/her immediate family, or his/her
employer/business (hereinafter an “interested person”) obtain a pecuniary benefit (see RSA
7:19-a) from the entity in the last year?
□ Yes □ No

3. Did the entity make a real estate transaction with or occupy real estate owned or rented by an
interested person?
□ Yes □ No

4. Was an advance or payment made on a loan to or from an interested person?
□ Yes □ No

5. For every “yes” answer to questions 2, 3, and 4, provide the following:
Name/Relationship of Description of Transaction (i.e.,
Name or Director/Officer/Trustee Amount
Interested Person car sale, salary, etc.)

6. Did any of the pecuniary benefit transactions listed in No. 5 above amount to $5,000 or more in
the aggregate during the fiscal year?

□ Yes □No

If yes, submit each of the following to the Charitable Trusts Unit:
○ Notice/letter sent to the Charitable Trusts Unit
○ Newspaper notice
○ Board meeting minutes approving the transaction

NOTE: The Director of Charitable Trusts may request copies of additional documentation relating to any pecuniary
benefit transaction, pursuant to RSA 7:24.

NHCT-12 (May 2024) www.doj.nh.gov/charitable-trusts/ charitabletrustsunit@doj.nh.gov

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7. Has the organization amended its formation documents (articles of agreement, declaration of
trust, constitution) or its bylaws within the reporting period?
□ Yes □No (If yes, submit a copy of the updated documents)

8. How many times did the board of directors meet during the reporting period?
□ 0 Times □ 1 Time □ 2 Times
□ 3 Times □ 4 Times □ More than 4 times

9. Did the entity use a professional solicitor, fundraising counsel, or commercial co-venturer to
solicit contributions on the entity’s behalf during the reporting period?
□ Yes □No (If yes, list their name(s) and address(es))

Name of Professional Fund Raiser or Commercial Co-Venturer Address

10. Was the entity the subject of any fine, penalty, or adverse judgment?
□ Yes □No (If yes, attach a copy of the document(s) related to the fine, penalty or adverse
judgment)

11. Is the entity a “fiscal sponsor” for another organization?
□ Yes □No (If yes, list the name and address of each organization

Name Address
City State Zip

City State Zip

12. Did the entity experience any significant thefts, embezzlements, or other diversions of assets
during the reporting period?
□ Yes □No

If yes, please explain:

NHCT-12 (May 2024) www.doj.nh.gov/charitable-trusts/ charitabletrustsunit@doj.nh.gov

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FORM NHCT-12: S  CHEDULE D                                                 Year-end:__________ 
  
                         CHARITABLE GIFT  NNUITY A ERTIFICATIONC                 

              Required for all charitable entities that issue charitable gift annuities in New Hampshire 

 1. The person signing Form NHCT-12 on behalf of this entity certifies that the organization has 
    entered into one or more charitable gift annuity agreements in New Hampshire and that each 
    such agreement is and shall be a qualified charitable gift annuity (as defined in NH RSA 403-E-
    1, V) in that on the date of the annuity agreement, it: (check each of the following to certify) 
         
     □ Has a minimum of $300,000 in unrestricted cash, cash equivalents, or publicly traded 
        securities, exclusive of the assets funding the annuity agreement; 
           
     □ Has been in continuous operation for at least 3 years or is a successor or affiliate of a 
        charitable entity that has been in continuous operation for at least 3 years; 
           
     □ Issues charitable gift annuities with payout ratios no greater than recommended by the 
        American Council on Gift Annuities at the time of issuance; 
           
     □ Retains 100 percent of the contribution made in exchange for each charitable gift annuity, 
        increased by earnings on the contribution and decreased by annuity payments and expenses 
        properly allocated to the annuity, until the annuity is terminated; and 
           
     □ Invests contributions made in exchange for charitable gift annuities solely in conformance 
        with article 9 of RSA 564-B, general standards of prudent investment. 
           
 2. Check the applicable box: 

     □ Initial notification; or 

     □ Annual recertification 

    NHCT-12 (May 2024)              www.doj.nh.gov/charitable-trusts/            charitabletrustsunit@doj.nh.gov 
                                                                                                          
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FORM NHCT-12: S  CHEDULE E                                                               Year-end: _________________ 
           
                                             WITHDRAWAL REPORT                            
                Complete for any entity that is withdrawing its registration with the Charitable Trusts Unit. 
                                                                      
1. Reason for withdrawal (check only one and attach requested documentation): 

                   Reason for Dissolution                                                Attachment Required 

A. □ Dissolution of NH nonprofit corporation                           NH Secretary of State Form NP-5 

B. □ Merger of NH nonprofit corporation                                The plan of merger filed with the Secretary of State, 
                                                                       pursuant to RSA 292:7 

C. □ Express trust termination                                         Document reflecting termination 

D. □ Dissolution of unincorporated association                         Minutes of the board meeting at which the vote to 
                                                                       dissolve was approved 

E. □ Cessation of charitable activities (only for non-                 Minutes of board meeting at which the vote to cease 
   §501(c)(3) organizations)                                           charitable activities was approved 

                                                                       NH Secretary of State Form FNP-5 (if not registered with 
F. □ Withdrawal from NH of foreign nonprofit corporation               NH Secretary of State, attach dissolution document filed in your 
                                                                       state) 
      
2. Charitable assets (by type and value) 
                Charitable Asset                                                         Asset Value 
                                                         
3. Distribution of assets   (not required if box 1F is checked above) 
                                                                                                       Recipient 
                                                                                                       Entity – 
                   Recipient                           Recipient                          Recipient 
Recipient                         Recipient                                                            federal tax 
                   Entity –                            Entity –       Recipient Entity –  Entity –                   Date of 
Entity –                          Entity –                                                             status 
                   contact                             phone          mailing address     Federal Tax                distribution 
name                              email address                                                        (501(c)(3) or 
                   name/title                          number                             ID number 
                                                                                                       other IRC 
                                                                                                       section) 
                                                                                                                      
         NHCT-12 (May 2024)                            www.doj.nh.gov/charitable-trusts/              charitabletrustsunit@doj.nh.gov 
                                                                                                                                 
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                                    CERTIFICATION 
                                              
 I hereby certify that the information in this report is true and correct to the best of my knowledge 
 and belief subject to penalty of making unsworn, false statements under RSA 641:3 and RSA 641:8. 

____________________________________________                           __________________________ 
Signature                                                              Date 
 
____________________________________________ 
Print Name of Signatory 
 
____________________________________________ 
Title 
(The certification must be signed by the presiding officer or treasurer of the governing board or a trustee of an express 
trust. This form may be signed by the executive director or other paid employee of the charitable organization only if the 
entity is not New Hampshire-based.) 
 
  NHCT-12 (May 2024)                 www.doj.nh.gov/charitable-trusts/      charitabletrustsunit@doj.nh.gov 
                                                                                                                            
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