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                                                                                                            Mail completed form to: 
                                                                                                            NH Attorney General’s Office 
                                                                                                            Attn: Charitable Trusts Unit 
                                                                                                            33 Capitol Street 
                                                                                                            Concord, NH 03301-6397 

  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 (September 2022)                                              www.doj.nh.gov/charitable-trusts/ charitabletrustsunit@doj.nh.gov 
                                                                                                                                             
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CHARITABLE TRUST UESTIONNAIREQ

1. Did the entity submit a request to extend the deadline to file the annual report with payment of the
$75.00 filing fee required by RSA 7:28-a, II?
□ Yes
□ No

2. Did the entity file with the IRS a Form 990, Form 990-EZ, or Form 990-PF for the reporting
period?
□ Yes
□ No (If no, complete Form NHCT-12, Schedule A.)

If yes, submit the form in lieu of Schedule A. If the entity also files an annual account with the New Hampshire Circuit
Court, Probate Division, submit that as well. NOTE: we do not accept the Internal Revenue Service Form 990-N.
Entities that file Form 990-N will need to complete the following Financial Report questions, Part I – Part III.

NH Entities Only: If the entity has revenue of more than $500,000, but less than $2 million, it must submit
a GAAP financial statement, pursuant to RSA 7:28, III-a. This financial statement may be prepared by the
entity in-house or may be prepared by an accountant and reviewed and approved by the entity. If the entity
has revenue of more than $2 million, it must file an audited financial statement examined by a certified
public accountant, pursuant to RSA 7:28, III-b. NOTE: this requirement does not apply to entities that file
Form 990-PF with the IRS.

3. Is the entity a New Hampshire nonprofit corporation (RSA 292) or otherwise headquartered in
New Hampshire?
□ Yes (if yes, and the entity is not a private foundation, complete Form NHCT-12, Schedule C.)
□ No

4. Does the entity issue/offer Charitable Gift Annuities to New Hampshire citizens?
□ Yes (if yes, complete Form NHCT-12, Schedule D)
□ No

5. Is this the entity’s final report (i.e., is your entity dissolving, withdrawing from registration)?
□ Yes (if yes, complete Form NHCT-12, Schedule E)
□ No

6. All charitable trusts are required to submit a governing board list (complete Form NHCT-12, Schedule B)

NHCT-12 (September 2022) www.doj.nh.gov/charitable-trusts/ charitabletrustsunit@doj.nh.gov

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FORMNHCT-12    CHEDULE: S              A                                            Year-end: __________________ 

FINANCIAL REPORT           

 A. Employer Identification Number     ____________________________________ 
  
 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: _______________________________________ 
     
 D. Describe briefly, for each of the entity’s largest programs (measured by expenses), the services provided 
     and the number of persons benefited (the program expense amounts must also be included within the expense category in 
     Part II, lines F8 through F16): 
              
                                   Description of Program                                     Program Expenses 
                                                                                      
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)                                     $ __________________ 

       NHCT-12 (September 2022)                  www.doj.nh.gov/charitable-trusts/        charitabletrustsunit@doj.nh.gov 
                                                                                                                            
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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)                           $__________________ 

Part III: Balance Sheet 

H.   Assets 
     1. Cash, savings, 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)               $ __________________ 

     NHCT-12 (September 2022)         www.doj.nh.gov/charitable-trusts/            charitabletrustsunit@doj.nh.gov 
                                                                                                       
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 M. Change in fund balance (subtract line L from line J)           $ __________________ 
     
 N. Explain reason for change in fund balance (line M) 
  
Part IV: Other Information 

 O.  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 (September 2022)  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. 

Name          Title            Home Address  Daytime    Email Address           Av. Hours           Compensation 
                                             Telephone                          per week            and benefits 
                                             Number                             devoted to          paid (enter 0 if 
                                                                                position            none) 
                                                                                                     
  1The 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. 
      NHCT-12 (September 2022)               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 (September 2022) 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-Venture 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

NHCT-12 (September 2022) 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 (September 2022)      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 filed with NH 
F. □ Withdrawal from NH of foreign nonprofit corporation             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                         Recipient                                          Recipient 
Recipient                         Recipient 
                   Entity –                          Entity –       Recipient Entity –  Federal Tax     Entity –    Date of 
Entity –                          Entity – 
                   contact                           phone          mailing address     ID number       federal tax distribution 
name                              email address 
                   name/title                        number                                             status 
                                                                                                                     
      NHCT-12 (September 2022)                    www.doj.nh.gov/charitable-trusts/               charitabletrustsunit@doj.nh.gov 
                                                                                                                                    
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                             CERTIFICATION 
  The certification must be signed by the president or treasurer of the governing board or a trustee of an express trust 
                                
 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 

  NHCT-12 (September 2022)    www.doj.nh.gov/charitable-trusts/      charitabletrustsunit@doj.nh.gov 
                                                                                                                          
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