Schedule I (Form 4 Taxes on Excess Benefit Transactions

1
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 5 of 6
PRINTS: HEAD TO FOOT
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ”) x 838mm (33”), TOP FOLD TO: 216mm (8 1⁄2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 4720 (2005)

Page

5

SCHEDULE G—Tax on Excess Lobbying Expenditures (Section 4911)
1

Excess of grassroots expenditures over grassroots nontaxable amount (from Schedule A (Form
990 or 990-EZ), Part VI-A, column (b), line 43). (See page 7 of the instructions before making
entry.)

1

Excess of lobbying expenditures over lobbying nontaxable amount (from Schedule A (Form 990
or 990-EZ), Part VI-A, column (b), line 44). (See page 7 of the instructions before making entry.)

2

3

Taxable lobbying expenditures—enter the larger of line 1 or line 2

3

4

Tax—Enter 25% of line 3 here and on page 1, Part I, line 6

4

2

SCHEDULE H—Taxes on Disqualifying Lobbying Expenditures (Section 4912)
Expenditures and Computation of Tax

Part I
(a) Item
number

(b) Amount

(c) Date paid
or incurred

(d) Description of lobbying expenditures

(e) Tax imposed on organization (f) Tax imposed on organization
managers (if applicable)—
(5% of col. (b))
(5% of col. (b))

1
2
3
4
5
Total—column (e). Enter here and on page 1, Part I, line 7
Total—column (f). Enter total (or prorated amount) here and in Part II, column (c), below

Part II

Summary of Tax Liability of Organization Managers and Proration of Payments
(a) Names of organization managers liable for tax

(b) Item no. from
Part I, col. (a)

(c) Tax from Part I, col. (f), or
prorated amount

(d) Manager’s total tax liability
(add amounts in col. (c))
(see page 7 of the instructions)

SCHEDULE I—Initial Taxes on Excess Benefit Transactions (Section 4958)
Part I
(a)
Transaction
number

Excess Benefit Transactions and Tax Computation
(b) Date of
transaction

(c) Description of transaction

1
2
3
4
5
(d) Amount of excess benefit

(e) Initial tax on disqualified persons
(25% of col. (d))

(f) Tax on organization managers
(if applicable) (lesser of
$10,000 or 10% of col. (d))

Form 4720 (2005)

1
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 6 of 6
PRINTS: HEAD TO FOOT
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ”) x 838mm (33”), TOP FOLD TO: 216mm (8 1⁄2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 4720 (2005)

Page

6

SCHEDULE I—Initial Taxes on Excess Benefit Transactions (Section 4958) Continued
Part II

Summary of Tax Liability of Disqualified Persons and Proration of Payments
(a) Names of disqualified persons liable for tax

Part III

(b) Trans. no. from
Part I, col. (a)

(c) Tax from Part I, col. (e),
or prorated amount

(d) Disqualified person’s total tax
liability (add amounts in col. (c))
(see page 8 of the instructions)

Summary of Tax Liability of 501(c)(3) & (4) Organization Managers and Proration of Payments

(a) Names of 501(c)(3) & (4) organization managers liable for tax

(b) Trans. no. from
Part I, col. (a)

(c) Tax from Part I, col. (f),
or prorated amount

(d) Manager’s total tax liability
(add amounts in col. (c))
(see page 8 of the instructions)

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief
it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Signature of officer or trustee

Title

Date

Signature (and organization name if applicable) of self-dealer, disqualified person, foundation manager, or organization manager

Date

Signature (and organization name if applicable) of self-dealer, disqualified person, foundation manager, or organization manager

Date

Signature (and organization name if applicable) of self-dealer, disqualified person, foundation manager, or organization manager

Date

Signature (and organization name if applicable) of self-dealer, disqualified person, foundation manager, or organization manager

Date

Signature of individual or firm preparing the return

Date

(
Address of preparer

)
Phone number of preparer

Form 4720 (2005)
Printed on recycled paper