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Currency [0]/Explanatory TextG5Explanatory Text % 0Good;Good  a%1 Heading 1G Heading 1 I}%O2 Heading 2G Heading 2 I}%?3 Heading 3G Heading 3 I}%234 Heading 49 Heading 4 I}% 5InputuInput ̙ ??v% 6 Linked CellK Linked Cell }% 7NeutralANeutral  e%"Normal 8Noteb Note   9OutputwOutput  ???%????????? ???:$Percent ;Title1Title I}% <TotalMTotal %OO= Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight16` icoverrgeneralinterrogatories statement)exhibits nsch aMsch bc sch dsch ef sch g footnotes   ;d8 8INCOMERGross amount of gifts received during the year conditioned upon annuity agreementsTotal%Annuity payments to donors and othersBalanceDGross interest due,_________________ and accrued____________________NAnnual Statement for the Year ______ of the __________________________________CNet present value of annuities. Give tables and rates of interest.#Deduct net value of risks reinsuredAnnuity payments due and unpaid Description Interest RateDate ofMaturityMoYear Par ValueCost StatementValue(Market Value)InterestReceivedAcquiredUS & Canadian Bonds:Foreign Bonds: Total - BondsXXXXXXXXXXXXXXNumber of SharesCostStatement Value DividendsUS & Canadian Stocks:Foreign Stocks: DepositoryTotal Cash in DepositoryCash in Company's Office Total Cash Location and Encumbrances/REINSURANCE RECOVERABLE ON PAID & UNPAID LOSSES Paid Losses:Unpaid Losses: At Beginningof YearWritten DuringTerminated DuringAt End No.PymtEnd of Current YearEnd Previous YearReserveAShowing all PREFERRED STOCKS owned at the end of the current year>Showing all COMMON STOCKS owned at the end of the current yearYesNo0members of the governing board or other officers%$____________________________________Annual Statementof theSegregated Gift Annuity FundofIn the State ofto the$of the Condition and Affairs of the of the QOrganized under the Laws of the State of ___________________________, made to the>Department of Banking and Insurance of the ǿ޴ýappPursuant to the Laws ThereofKMail Address ________________________, ___________________________________NAdministrative Office ___________________, ___________________________________%Phone (_____) ______________________KContact Person and Phone Number __________________________________________OFFICERS$State of ___________________________$County of __________________________hof the __________________________________________________ being duly sworn, each for himself deposes andtappropriation by the corporation of funds legally transferable to the general funds thereof) free and clear from anyand belief, respectively.rliens or claims thereon, except as above stated, and that the foregoing statement, with the schedules and explain-{tions therein contained, annexed or referred to is a full and correct Exhibit of all of the Assets, Liabilities, Income andD____________________________________________________________________XPrincipal Officer ____________________________ ___________________________________VSecretary ________________________________ ___________________________________VTreasurer ________________________________ ___________________________________VActuary _________________________________ ___________________________________S__________________________ ___________________________ _________________________f______________________ President, _______________________ Secretary _____________________ *Treasurer __________V*Or corresponding person having charge of the accounts and finance of the Corporation.!Department of Banking & Insurance(Street)(City, State, Zip)+**Show full name (initials not acceptable) DIRECTORS OR TRUSTEES** (Give Title)NameTitlevSubscribed and sworn to before me on this _______ ___________________________ President**|day of _____________________, _____ ___________________________ Secretary**z_________________________________ ___________________________*Treasurer**+**Two of the three signatures are required.7If Yes, identify the rate table and its effective date.,Has the prior year's statement been amended?!If Yes, please explain in detail.LWas there a change in the assumptions used to calculate the present value ofpayments due to annuitants?OHave there been included in this statement proper reserves to cover liabilitiesLDid any person while an officer, director, member of the governing board or JHas any change been made during the year of this statement in the charter,6If Yes, have the forms been filed with the Department?OHas the IRS exemption expired, been cancelled, or is it being challenged by theIRS?SCHEDULE A - BONDS;If Yes, give full and complete information relating theretoOther disbursements (Itemize) All other liabilities (Itemize)Name of Reinsurer:Address: FootnotesRequired Surplus:Excess Surplus:2Monies over and above reserve and required surplusHExhibit of Number and Annual Payments of Annuities in Force and ReservesNo. = Number of annuities-Pymt. = Annualized payment on those annuitiesHAnnual Statement for the Year ______ of the ____________________________Realized Gain/(Loss)Unrealized Gain/(Loss)3The monetary result of the actual sale of an asset.:The monetary result that would occur if the entity were to7sell an asset at its market price at a given moment. Aentity holds the asset. approval.-Market value of bonds (Schedule A, Column 6)20 West State St. P.O. Box 325Trenton, NJ 08625-0325Contact Information:20 West State Street/For the Year Ended ____________________________,For the Year Ended ________________________mDisbursements, and of the condition and affairs of the said corporation's segregated annuity fund on the lastLday of the year ended, according to the best of their information, knowledgehall of the above described assets were segregated and held as a separate and distinct fund, (subject to isays that they are the above described officers of the said corporation, and that on the statement date, Cwhich no notice was received at the home office until subsequently?Lwhich may have been actually incurred on or before the statement date but ofITotal amount of loans outstanding as of the statement date to directors, JWere all the stocks, bonds and other securities owned as of the statement Be-mail address __________________________________________________Rating Bond Funds Stock Funds Sub TotalTotal CUSIP # or Stock SymbolRedeem- able (Y/N)CUSIP or=Showing all MUTUAL FUNDS owned at the end of the current yearTotal - Common StocksTotal - Preferred Stocks!Dividends received on sold stock:'Dividends received on mutual funds sold3Market value of mutual funds (Schedule D, Column 5)IEXHIBIT OF NUMBER AND ANNUAL PAYMENTS OF ANNUITIES IN FORCE AND RESERVES6H*$100,000 or 10% of reserves on outstandingSCHEDULE D - MUTUAL FUNDS#SCHEDULE E - CASH, MONEY MARKET, CDSCHEDULE F - ALL OTHER ASSETS Interest received on sold bonds:ASSETS BALANCE SHEETEXPENSES"Previous year Annuity Fund BalanceRequired surplus2 Excess surplus3 Investment Income:Other income (itemize)4a. Realized4 4b. Unrealized5 "Total Income (lines 1 through 4b)Gain on investmentsLoss on investments$STATEMENT OF CHANGES IN ANNUITY FUNDSCHEDULE B - PREFERRED STOCKSSCHEDULE C - COMMON STOCKS4Market value of common stocks (Schedule C, Column 5)7Market value of preferred stocks (Schedule B, Column 6)!Total assets (lines 1 through 7)Net Reserve (lines 9 and 10)6Total amount of all liabilities (lines 11 through 13)Real Estate FundsInterest Rec'd. Closed Accts. Monies Rec'd. on Disposed AssetsDHas there been any change in name or organizational status since the5date of the last statement filed with the Department?( )IHave all the transactions related to annuity agreements, of which notice of the segregated account?+If No, provide custodians name and address.HWere any of the stocks, bonds or other assets of the segregated account <by another person during the year covered by this statement?Jloaned, placed under option agreement, or otherwise made available for useSarticles of incorporation, or articles of association of < the special permit holder?ZIn what states is the special permit holder authorized to issue charitable gift annuities?Idate, in the actual possession of the special permit holder on said date?NHas the special permit holder filed a copy of its currently effective annuity 9from the rates of the American Council on Gift Annuities.JIf No, include a copy of the table with the Annual Statement if it differsIf Yes, explain.%supervised the making of this report?EWhat officials and heads of departments of the special permit holder ?was received on or before the close of the statement date, been/truthfully and accurately entered on the books?4records and data at the close of the statement date?Ishow the condition of the segregated annuity fund as shown by the books, EExcept as shown in the next succeeding question, does this statement Lmember of the governing board or other officers, $_________________________.NTotal amount loaned from the segregated account during the year to directors, Nperiod covered by this statement, any commission on the business transactions Ptrustee of the special permit holder receive directly or indirectly, during the IIf Yes, provide a copy of the amended document with the Annual Statement.<issued to annuitants since the last annual statement filing?HHas the special permit holder amended or revised the forms of agreement QAre you authorized to issue charitable gift annuities in the State of California?Lpassed upon either by its governing body or a subordinate committee thereof?GIs the purchase or sale of all investments of the special permit holderIproceedings of its governing body and all subordinate committees thereof?FDoes the special permit holder keep a complete permanent record of theFHave there been any changes to the organization that would change the ?provisions for which your New Jersey special permit was issued?of the special permit holder?MDoes the special permit holder maintain the assets of the segregated account Pin a separate and distinct account, physically segregated from the other assets :Registered Agent _________________________________________DIf No, provide current blank forms with the Annual Statement filing.'payout rate table with this Department?>Has your method of accounting for the segregated fund changed?/Any change to the basis will require Department!agreements, whichever is greater. Jurisdiction:6Showing all BONDS owned at the end of the current yearOther (Schedule F, Column 4)JURATPIf Yes, please complete Exhibit of Segregated Account by Jurisdiction on page 8."2a. Bonds (Schedule A, Column 7)-2b. Preferred Stocks (Schedule B, Column 7))2c. Common Stock (Schedule C, Column 6))2d. Mutual Funds (Schedule D, Column 6))2f. Other Assets (Schedule F, Column 5)-Exhibit of Segregated Account by JurisdictionHeld for the Benefitof a Particular JurisdictionsAnnuitants and Beneficiaries of All Other Description of Asset6capital gain or loss remains unrealized as long as the5Indicate which basis, cash or accrual, is being used.Assets (pg. 6, line 8)Reserve (pg. 6, line 11)Other (pg. 6, lines 12 & 13)Surplus (pg. 6, lines 15 & 16)"LIABILITIES, SURPLUS & OTHER FUNDSRTotal liabilities and surplus (lines 14 through 16; should equal line 8 above and.Cash, Money Market, CD (Schedule E, Column 3)32e. Cash, Money Market, CD (Schedule E, Column 4)EXHIBITSHBasis1 of Income Recognition: _______ Cash or _______Accrual RecognitionBasis of Income UIncorporated ____________________ Federal ID #_____________________SCHEDULE G - REINSURANCE(Showing all annuity agreements reinsured Date AnnuityAgreement IssuedName of ReinsurerDate Agreement ReinsuredReinsurance PremiumPaid Total ReserveCededCopy of ReinsuranceContract Attached or Date Submitted5Reinsurance Ageements entered during the current year8Reinsurance Ageements outstanding at the end of the yearxxxxxAnnuitant Name/and or Agreement Number;Reinsurance premiums paid (Schedule G, Section 1, Column 6)9a. Realized4 9b. Unrealized5 *Total Expense (sum of lines 6 through 9b)1Net Change in Annuity Fund (line 5 minus line 10)5Annuity Fund Balance at end of year (lines 11 and 12) Section 1 Section 2page 7, line 13)/Attn: Office of Solvency Regulation, 8th FloorFax: 609-292-6765 June DugganPhone: 609-292-5350 ext. 50326%E-Mail: june.duggan@dobi.state.nj.us:5 s77L8[829A9I:XQ;`<.=@ B C E GH J/KXMgNTOcPrQIRXSUjWU1Y[~]_ ` a [cF dQe<"f Ug@ccB g2ɀ nq  dMbP?_*+%&C&P&?'?(?)?M6HP DeskJet 895CxiXC od,,LetterDINU"4$%#| $$$$"d,,??&U} S       jk k? k@ kA k@k k l m m pB pCooo kD k_ k3 k k kkkk kkn@D     >@7ggD g2ɀ Qv1|  dMbP?_*+%&C&P&?'?(?)?M6HP DeskJet 895CxiXC od,,LetterDINU"4$%#| $$$$"d,,??&UQ  8 8                           E?EEEEEEEE EEEEEEEEE EEEEEEEEEE EAEEEEEEEE EFEEEEEEEEEEEEEEEEE EVEEEEEEEE EEEEEEEEE EG EEEEEEEE EH EEEEEEEE EI EEEEEEEE EEEEEEEEE  J r` ra K r` ra L M  ANAAAAAAAA W rd re sf X re sf:2(((((((((((* ! 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