SM
Section 5; View 5.122; Version 1.1
Trust Entity without 501 c 3 status --Face Sheet
Enter the common name of your organization
______
Please enter your name and contact information -- phone or email address (person preparing).
______
1. In approximately 500 words or less, please provide a general description of your business. Please refer to your mission and vision.
(Your answer here – expand space as needed)
2. Please identify your primary competition and what makes you special, different, or better.
3. Legal name of trust
______
4. Legal Address:
______
5. City: ______6. State or Province: ___
7. Postal Code: ______8. Country, if not US: ______
9. List any DBA names (“Doing business as”), that is, other names by which this trust is known.
(Your response here. Expand space as needed)
10. Do you engage a Contract Management firm? If so, please identify that firm here.
10.01 Name of Firm______
10.02 If firm has responded previously, give the unique ID number from their
response______10.03 Name: ______
10.04 Title: ______
10.05 Address: ______
______
10.06 City: ______10.07 State or Province: _____
10.08 Postal Code: ______10.09 Country, if not US: ______
10.10 Telephone: ______10.11 Fax: ______
10.12 Email: ______
11.1. Jurisdiction (court) with authority to supervise trust:
(Your response here. Expand space as needed)
11.2.Legal language of purpose of trust:
(Your response here. Expand space as needed)
12. How are trustees selected? To whom are they accountable? Please be specific and detailed. Attach documents that might be helpful.
(Your response here. Expand space as needed)
13. Identify all persons and legal entities (if any)other than the court and the trustees themselves having jurisdiction over the trust and the trustees. Include anyone with legal authority to select or participate in the selection of trustees. If any external person or legal entity has over more 5% of control, (for example, controls selection of over more than 5% of the voting authority of the trustees, we want them identified. Your response, signed by the person who verifies the accuracy of your responses, asserts that those listed are the entirety of the legal authority governing the trust. Add additional spaces as needed. Enter “none” at 13.1 if appropriate. (We believe that “none” will be the most frequent response) If the trustees as group have the authority to fill trustee vacancies, that need not be reported here.
13.1. How many natural persons have jurisdiction over trust and/or trustees as defined in the previous paragraph – 13? (We are not asking for trustees here but for people with power to select them. Trustees are listed in item 16)
X______(If you entered “0” or “none,” skip to #15)
13. 2. List the natural persons as described in 13 that control the actual appointment of trustees. The name you use need not be that person’s full legal name. We will get that from you later. Note that 01, 02, 03, etc. are “natural person numbers.” You will need to keep these in mind on View 5.1211.
13.201 Natural person 01 (Name): ______
13.202 Natural person 02 (Name): ______
13.203 Natural person 03 (Name): ______
13.204 Natural person 04 (Name): ______
13.3 If you have more than sixnatural persons, you may add to this list yourself. Take additional space as needed, but follow the format as shown. Number the first added Natural Person as “13.205 Natural Person 05 ______” right under “Natural Person 04” forcing this paragraph down the page. Continue numbering with 13.205.
14. For each person listed above, you need to download one copy of Section 5, View 5.1211. and enter the Natural Person numberinto the blank space in Section 5 View 5.1211, line number 1.1, where it says “‘Natural Person Number’ for the Natural Person to be described herefrom Section 5, View 5.121 or 5.122, Item 13.2.” and the brief descriptive name where it says, “Name as shown on View 5.121 or 5.122, Item 13.2” in item 2.
14.1 As you respond to questions on each copy of View 5.121, the View number is revised. Make sure you save each copy with a file name that ends with the revised View number. The saved copy of View 5.1211 that describes the entry at 13.201 becomes View number 5.1211.01 and you must give it a file name that ends with 5.1211.01.doc when you save it. The saved copy of View 5.1211 that describes the entry at 13.202 becomes View number 5.1211.02 and you must give it a file name that ends with 5.1211.02.doc. Etc. The View number just assigned must be entered at item 1.2 on the appropriate copy of View 5.1211.
15. Still responding to item 13, identify any external legal entitiesthat are not natural persons having control. Enter “0” or “none” in 15.1 if appropriate. If the trustees as group choose have the authority to fill vacancies, that need not be reported here.
15.1. How many legal entities that are not natural persons have jurisdiction over trust as defined in the previous paragraph (15)?
X______(If you entered “0” or “none,” skip to #16)
15. 2. List any outsideLegal Entities as described in 13 that control the actual appointment of trustees. The name you use need not be that entity’s full legal name. We will get that from you later. Note that 15.201, 15.202, 15.203, etc. are “Legal Entity numbers.” You will need to keep these in mind on View 5.1212.
15.201 Other Legal Entity 01: (Name):______
15.202 Other Legal Entity 02: (Name):______
15.203 Other Legal Entity 03: (Name):______
15.204 Other Legal Entity 04: (Name):______
15.3 If you have more than fourLegal Entities, you may add to this list yourself. Take additional space as needed, but follow the format as shown. Number the first added Legal Entity as “15.205 Legal Entity 05 ______” right under “Legal Entity 04” forcing this paragraph down the page. Continue numbering from15.205.
For each legal entity listed above, you need to download one copy of Section 5, View 5.1222 and enter the Legal Entity numberinto the blank space in Section 5 View 5.1212, line number 1.1, where it says “‘Legal Entity Number’ forthe Legal Entity to be described herefrom Section 5, View 5.121 or 5.122, Item 15.2.” and the brief descriptive name where it says, “Name as shown on View 5.121 or 5.122, Item 15.2” in item 2.
16. Tellus about your Trustees. Your organization may have a different name than “Trustee.” We are interested in the person or people who have the duties generally assigned to trustees.
(You may enter an optional comment here – Expand space as necessary)
16.1 Tell us the correct titles, duties and responsibilities common to the trustees. Individual situations that vary from this will be reported elsewhere.
(Your response here – expand space as necessary)
16.2 How many trustees do you have? X______
16.3 Please list those trustees. Note that Trustee 01, Trustee 02, Trustee 03, etc. are “Trustee Numbers.”
16.301 Trustee 01 (Name): ______
16.302 Trustee 02 (Name): ______
16.303 Trustee 03 (Name): ______
16.304 Trustee 04 (Name): ______
16.305 Trustee 05 (Name): ______
16.306 Trustee 06 (Name): ______
16.4 If you have more than Six Trustees, you may add to this list yourself. Take additional space as needed, but follow the format as shown. Number the first added Trustee as “16.307 Trustee 07 ______” right under “Trustee 06” forcing this paragraph down the page. Continue numbering from16.307.
17. For each person listed above, you need to download one copy of Section 5, View 5.1213and enter the TrusteeNumberinto the blank space in Section 5 View 5.1213, line number 1.1, where it says “‘Trustee Number’ forthe Trustee to be described herefrom Section 5, View 5.121 or 5.122, Item 16.3.” and the brief descriptive name where it says, “Name as shown on View 5.121 or 5.122, Item 16.3.
18. Please identify your Chief Executive Officer (whether or not that is the title you use). We refer to the most senior person actually functioning as a full time manager or executive, reporting to the Trustees.
18.01 Name: ______18.02 Title: ______
18.03 Address: ______
18.04 City: ______18.05 State or Province: ___
18.06 Postal Code: ______18.07 Country, if not US: ______
18.08 Telephone: ______18.09 Fax: ______
18.10 Email: ______
19. Please identify your Chief Operating Officer (whether or not that is the title you use) if that is different from your CEO. We refer to the most senior person actually directing day to day operations, reporting to the CEO or perhaps to the board or to investors. If there is not a separate position for this, write “none.”
19.01 Name: ______19.02 Title: ______
19.03 Address: ______
19.04 City: ______19.05 State or Province: ___
19.06 Postal Code: ______19.07 Country, if not US: ______
19.08 Telephone: ______19.09 Fax: ______
19.10 Email: ______
20. Please identify your Chief Financial Officer (whether or not that is the title you use) if that is different from your CEO or COO. We refer to the most senior person actually managing finances, reporting to the CEO or perhaps to the board or to investors. If there is not a separate position for this, write “none.”
20.01 Name: ______20.02 Title: ______
20.03 Address: ______
20.04 City: ______20.05 State or Province: ___
20.06 Postal Code: ______20.07 Country, if not US: ______
20.08 Telephone: ______20.09 Fax: ______
20.10 Email: ______
21. Principal Business Contact (person normally to be contacted on routine business matters – not admissions or enrollments):
21.01 Name: ______21.02 Title: ______
21.03 Address: ______
21.04 City: ______21.05 State or Province: ___
21.06 Postal Code: ______21.07 Country, if not US: ______
21.08 Telephone: ______21.09 Fax: ______
21.10 Email: ______
21.11. Please attach an organization chart of your organization.
22. Name and contact information of person responsible for accuracy of questionnaire: (This person will need to initial each page submitted and sign the final page affirming accuracy. It is acceptable for different people to complete different sections and views of questionnaire, but one person must take responsibility for affirming accuracy.)
22.01 Name: ______22.02 Title: ______
22.03 Address: ______
22.04 City: ______22.05 State or Province: ___
22.06 Postal Code: ______22.07 Country, if not US: ______
22.08 Telephone: ______22.09 Fax: ______
22.10 Email: ______
22.11 Best time to contact:
23. Please enter any comments here(Expand space as needed):
______
______
______
If you have an A, B or C number of 9 or in the range 90-99, email us at and tell us the problem.
Please remember to enter Unique ID and Submission number in the “footer” section of this document. Do not enter “New Page Number” or “Initials” until after printing when the entire questionnaire is complete.
Thank you!
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New page number ______Unique ID ______Submission #______Initials ______
Section 5 View 5.122 © 2009 Thomas J. Croke and Associates, Inc.