Form 440-4017 "Master Trustee Annual Report and Registration Renewal" - Oregon

What Is Form 440-4017?

This is a legal form that was released by the Oregon Department of Consumer and Business Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the Oregon Department of Consumer and Business Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 440-4017 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

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Download Form 440-4017 "Master Trustee Annual Report and Registration Renewal" - Oregon

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Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfcs.oregon.gov
MASTER TRUSTEE ANNUAL REPORT AND REGISTRATION RENEWAL
ORS Chapter 97; OAR 441-930
Reporting period: Jan. 1 to Dec. 31
For calendar year:
Due date: April 1
Fee:
$390
Business name:
ABN (if applicable):
Business address:
City, state, ZIP:
Business phone:
Business fax:
Business e-mail:
Contact name:
Mailing address, if different from above:
City, state, ZIP:
1.
Beginning balance of trust on Jan. 1 (ending market value of previous report) ...................... $
2.
Deposits made in reporting year .............................................................................................. $
3.
Interest/dividends/gains/losses ................................................................................................. $
4.
Trustee, accounting, depository, and investment fees (limited to 2% of Line 1) ..................... $ (
)
5.
Taxes paid for the benefit of contract beneficiaries ................................................................. $ (
)
6.
Withdrawals ............................................................................................................................. $ (
)
7.
Ending balance on Dec. 31 reporting year (market value) ....................................................... $
Provide the following with your annual report:
Payment of annual fee
Alphabetical list of legal names and location of each certified provider, certified provider number, total number of
unfulfilled contracts, and the total amount of trust funds on deposit for each.
Signature:
Title:
Type or print name:
Date:
Phone:
Secure fax for credit card payments:
Make check or money order payable to the Department of
503-947-2333
Consumer and Business Services. Mail application with
If paying by credit card, applicant must sign
payment to:
DCBS — Fiscal Services
credit-card information box.
P.O. Box 14610
Salem, OR 97309-0445
Visa
MasterCard
Discover
Phone:
Fiscal use only: 61260/1008
Credit card number
Expiration date
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
440-4017 (1/12/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfcs.oregon.gov
MASTER TRUSTEE ANNUAL REPORT AND REGISTRATION RENEWAL
ORS Chapter 97; OAR 441-930
Reporting period: Jan. 1 to Dec. 31
For calendar year:
Due date: April 1
Fee:
$390
Business name:
ABN (if applicable):
Business address:
City, state, ZIP:
Business phone:
Business fax:
Business e-mail:
Contact name:
Mailing address, if different from above:
City, state, ZIP:
1.
Beginning balance of trust on Jan. 1 (ending market value of previous report) ...................... $
2.
Deposits made in reporting year .............................................................................................. $
3.
Interest/dividends/gains/losses ................................................................................................. $
4.
Trustee, accounting, depository, and investment fees (limited to 2% of Line 1) ..................... $ (
)
5.
Taxes paid for the benefit of contract beneficiaries ................................................................. $ (
)
6.
Withdrawals ............................................................................................................................. $ (
)
7.
Ending balance on Dec. 31 reporting year (market value) ....................................................... $
Provide the following with your annual report:
Payment of annual fee
Alphabetical list of legal names and location of each certified provider, certified provider number, total number of
unfulfilled contracts, and the total amount of trust funds on deposit for each.
Signature:
Title:
Type or print name:
Date:
Phone:
Secure fax for credit card payments:
Make check or money order payable to the Department of
503-947-2333
Consumer and Business Services. Mail application with
If paying by credit card, applicant must sign
payment to:
DCBS — Fiscal Services
credit-card information box.
P.O. Box 14610
Salem, OR 97309-0445
Visa
MasterCard
Discover
Phone:
Fiscal use only: 61260/1008
Credit card number
Expiration date
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
440-4017 (1/12/COM)