Form 4720

2006 Form 4720, Return of Excise Taxes Under Chapters 41 and 42 of
the Internal Revenue Code.
Purpose: This is the first circulated draft of the 2006 Form 4720, Return
of Excise Taxes Under Chapters 41 and 42 of the Internal Revenue Code for your review
and comments. See below for a discussion of the major changes.
TPCC Meeting: None but one may be arranged if requested.
Prior Version: The 2005 Form 4720 is available at:
http://publish.no.irs.gov/FORMS/PUBLIC/PDF/13021Y05.PDF
Instructions: The 2005 Instructions to Form 4720 are available at:
http://publish.no.irs.gov/INSTRS/PDF/13023Y05.PDF
Other Products: Circulations of draft tax forms, instructions, notices and publications
are posted at: http://taxforms.web.irs.gov/draft_products.html
Comments: Please email, fax, call or make any comments by January 4, 2006

Carl Medley
Tax Law Specialist
TE/GE Forms and Publications
SE:W:CAR:MP:T:T:FP
(202) 622-5318
(202) 283-0837

[email protected]

Major Changes to Form 4720, Return of Excise Taxes Under
Chapters 41 and 42 of the Internal Revenue Code
We updated years and dates as necessary and made miscellaneous editorial
changes throughout.
Heading- We changed the title of the form.
-

We added IRC sections 4965, 4966, and 4967

Part I – Taxes on Organization
-

We added sections 4965(a)(1), and 4966(a)(1)
We changed line 10 to provide for the tax on taxable distributions from
Schedule K and we added line 11.

Part II-A
-

We added sections 4965(a)(2), 4966(a)(2) and 4967(a)
We revised the table to include columns to enter information from Schedules
J, K, and L.

Part II-B
- We changed line 2 to read “Total Tax, Add Part I, line 11 instead of line 10.
Schedule- A
-

We changed the headings in columns (f) and (g) to reflect new amounts
resulting from the Pension Protection Act of 2006 (PPA)

Schedule - B
-

We changed the amount on line 4 to reflect new amounts resulting from
(PPA)

Schedule –C
-

We changed the amount on line 6 to reflect new amounts resulting from
(PPA)

Schedule –D
-

We changed the headings in columns (e) and (f) to reflect new amounts
resulting from the Pension Protection Act of 2006 (PPA)

Schedule –E

-

We changed the headings in columns (g) and (h) to reflect new amounts
resulting from the Pension Protection Act of 2006 (PPA).

Schedule - F
-

We changed the headings in columns (e) and (f) to reflect new amounts
resulting from the Pension Protection Act of 2006 (PPA).

Schedule –H
-

We changed the headings in columns (e) and (f) to reflect new amounts
resulting from the Pension Protection Act of 2006 (PPA).

Schedule – I
-

We changed the headings in columns (e) and (f) to reflect new amounts
resulting from the Pension Protection Act of 2006 (PPA).

We added new Schedules J, K, and L

5
TLS, have you
transmitted all R
text files for this
cycle update?

Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 1 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form

4720

Department of the Treasury
Internal Revenue Service

Action

Date

O.K. to print
Revised proofs
requested

Return of Certain Excise Taxes Under Chapters
41 and 42 of the Internal Revenue Code

OMB No. 1545-0052

2006

(Sections 170(f)(10), 4911, 4912, 4941, 4942, 4943, 4944, 4945, 4955, 4958, 4965, 4966, and 4967)
© See separate instructions.

For calendar year 2006 or other tax year beginning
Name of organization or entity

Signature

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, 2006, and ending

, 20

.

Employer identification number

..
..

Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)

Check box for type of annual return:
Form 990

City or town, state, and ZIP code

Form 990-EZ

Form 990-PF
Form 5227

A
B

Is the organization a foreign private foundation within the meaning of section 4948(b)?
Has corrective action been taken on any taxable event that resulted in Chapter 42 taxes being reported on this
form? (Enter “N/A” if not applicable)
If “Yes,” attach a detailed description and documentation of the corrective action taken and, if applicable, enter the fair market
value of any property recovered as a result of the correction © $
. If “No,” (i.e., any uncorrected
acts, or transactions), attach an explanation (see page 3 of the instructions).

Taxes on Organization (Sections 170(f)(10), 4911(a), 4912(a), 4942(a), 4943(a), 4944(a)(1), 4945(a)(1),
4955(a)(1), 4965(a)(1), and 4966(a)(1))

Part I
1
2
3
4
5
6
7
8
9
10
11

Yes No

Tax on undistributed income—Schedule B, line 4
Tax on excess business holdings—Schedule C, line 7
Tax on investments that jeopardize charitable purpose—Schedule D, Part I, column (e)
Tax on taxable expenditures—Schedule E, Part I, column (g)
Tax on political expenditures—Schedule F, Part I, column (e)
Tax on excess lobbying expenditures—Schedule G, line 4
Tax on disqualifying lobbying expenditures—Schedule H, Part I, column (e)
Tax on premiums paid on personal benefit contracts
Tax on being a party to prohibited tax shelter transactions—Schedule J, Part I, column (h)
Tax on taxable distributions—Schedule K, Part I, column (d)
Total (add lines 1–10)

Part II-A

1
2
3
4
5
6
7
8
9
10
11

Taxes on Self-Dealers, Managers, Disqualified Persons, Donors, Donor Advisors, and Related Persons
(Sections 4912(b), 4941(a), 4944(a)(2), 4945(a)(2), 4955(a)(2), 4958(a), 4965(a)(2), 4966(a)(2), and 4967(a))
(b) Taxpayer
identification number

(a) Name and address of person subject to tax

a
b
c
d
(c) Tax on self-dealing—
Schedule A, Part II, col. (d)

(d) Tax on investments that jeopardize
charitable purpose—Schedule D,
Part II, col. (d)

(e) Tax on taxable expenditures—
Schedule E, Part II, col. (d)

(f) Tax on political expenditures—
Schedule F, Part II, col. (d)

(g) Tax on disqualifying lobbying
expenditures—Schedule H, Part II, col. (d)

(h) Tax on excess benefit transactions—
Schedule I, Part II, col. (d)

(i) Tax on prohibited tax shelter
transactions—Schedule J, Part II, col. (d)

(j) Tax on taxable
distributions—Schedule K,
Part II, col. (d)

a
b
c
d
Total

a
b
c
d
Total
(k) Tax on prohibited benefits—Sch L,
Part II, col. (d), and Part III, col. (d)

(l) Total—Add cols. (c) through (k)

a
b
c
d
Total
For Privacy Act and Paperwork Reduction Act Notice, see page 14 of the instructions.

Cat. No. 13021D

Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 2 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 217mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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Form 4720 (2006)

Part II-B
1

Page

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Enter the taxes listed in Part II-A, column (i), that apply to self-dealers, managers, disqualified
persons, donors, donor advisors, and related persons who sign this form. If all sign, enter
the total amount from Part II-A, column (l)
Total tax. Add Part I, line 11, and Part II-B, line 1. (Make check(s) or money order(s) payable
to the United States Treasury.)

2

2

Summary of Taxes (See Tax Payments on page 4 of the instructions.)

1
2

SCHEDULE A—Initial Taxes on Self-Dealing (Section 4941)
Part I
(a) Act
number

Acts of Self-Dealing and Tax Computation
(b) Date
of act

(c) Description of act

1
2
3
4
5
(d) Question number from Form 990-PF,
Part VII-B, or Form 5227, Part VI-B,
applicable to the act

Part II

(e) Amount involved in act

(g) Tax on foundation managers (if
applicable) (lesser of $10,000/20,000
or 21⁄ 2 %/5%* of col. (e))

Summary of Tax Liability of Self-Dealers and Proration of Payments
(a) Names of self-dealers liable for tax

Part III

(f) Initial tax on self-dealing
(5%/10%* of col. (e))

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

(d) Self-dealer’s total tax
liability (add amounts in col. (c))
(see page 6 of the instructions)

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

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

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

(d) Manager’s total tax liability
(add amounts in col. (c))
(see page 6 of the instructions)

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

SCHEDULE B—Initial Tax on Undistributed Income (Section 4942)
1
2
3

Undistributed income for years before 2005 (from Form 990-PF for 2006, Part XIII, line 6d)
Undistributed income for 2005 (from Form 990-PF for 2006, Part XIII, line 6e)
Total undistributed income at end of current tax year beginning in 2006 and subject to tax
under section 4942 (add lines 1 and 2)

4 Tax—Enter 15%/30%* of line 3 here and on page 1, Part I, line 1
* For tax years beginning after 8/17/2006.

1
2
3
4
Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 3 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Page

3

SCHEDULE C—Initial Tax on Excess Business Holdings (Section 4943)

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Business Holdings and Computation of Tax

If you have taxable excess holdings in more than one business enterprise, attach a separate schedule for each enterprise. Refer
to the instructions on page 7 for each line item before making any entries.
Name and address of business enterprise

©

Employer identification number

Form of enterprise (corporation, partnership, trust, joint venture, sole proprietorship, etc.)
(a)
Voting stock
(profits interest or
beneficial interest)

©

(c)
Nonvoting stock
(capital interest)

(b)
Value

1

Foundation holdings in business enterprise

1

%

%

2

Permitted holdings in business enterprise

2

%

%

3
4

Value of excess holdings in business enterprise
Value of excess holdings disposed of within 90
days; or, other value of excess holdings not
subject to section 4943 tax (attach explanation)

3

5

Taxable excess holdings in business enterprise—
line 3 minus line 4

6
7

Tax—Enter 5%/10%* of line 5
Total tax—Add amounts on line 6, columns (a), (b),
and (c); enter total here and on page 1, Part I, line 2

4
5
6
7

SCHEDULE D—Initial Taxes on Investments That Jeopardize Charitable Purpose (Section 4944)
Part I

Investments and Tax Computation

(a) Investment
number

(b) Date of
investment

(c) Description of investment

(d) Amount of
investment

(e) Initial tax on
foundation
(5%/10%* of col.
(d))

(f) Initial tax on foundation
managers (if applicable)—
(lesser of $5,000/10,000%
or 5%/10%* of col. (d))

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

Part II

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

* For tax years beginning after 8/17/2006.

(b) Investment
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 9 of the instructions)

Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 4 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Page

4

SCHEDULE E—Initial Taxes on Taxable Expenditures (Section 4945)
Part I
(a) Item
number

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Expenditures and Computation of Tax
(b) Amount

(c) Date paid
or incurred

1
2
3
4
5
(f) Question number from Form 990-PF, Part VII-B, or
Form 5227, Part VI-B, applicable to the expenditure

Total—column (g). Enter here and on
page 1, Part I, line 4

(d) Name and address of recipient

(e) Description of expenditure and purposes
for which made

(g) Initial tax imposed on foundation
(10%/20%* of col. (b))

(h) Initial tax imposed on foundation
managers (if applicable)—(lesser of
$5,000/$10,000 or 21⁄ 2 %/5%* of col. (b))

Total—column (h). Enter total (or prorated amount) here and in Part II, column (c),
below

Part II

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

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

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

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

SCHEDULE F—Initial Taxes on Political Expenditures (Section 4955)
Part I
(a) Item
number

Expenditures and Computation of Tax
(b) Amount

(c) Date paid
or incurred

(d) Description of political expenditure

(e) Initial tax imposed on
organization or foundation
(10% of col. (b))

(f) Initial tax imposed on
managers (if applicable) (lesser
of $5,000 or 21⁄ 2% of col. (b))

1
2
3
4
5
Total—column (e). Enter here and on page 1, Part I, line 5
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 or Foundation Managers and Proration of Payments
(a) Names of organization managers or
foundation managers liable for tax

* For tax years beginning after 8/17/2006.

(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 11 of the instructions)

Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 5 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Page

5

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

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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 11 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 11 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

1
2
3
4
5

(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))

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 11 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

*For tax years beginning after 8/17/2006.

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

(f) Tax on organization managers
(if applicable) (lesser of
$10,000/$20,000* or 10% of col. (d))

Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 6 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Page

6

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

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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)

(d) Disqualified person’s total tax
liability (add amounts in col. (c))
(see page 13 of the instructions)

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

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)

(d) Manager’s total tax liability
(add amounts in col. (c))
(see page 13 of the instructions)

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

SCHEDULE J—Taxes on Being a Party To Prohibited Tax Shelter Transactions (Section 4965)
Part I
(a)
Transaction
number

Prohibited Tax Shelter Transactions (PTST) and Tax Imposed on the Tax-Exempt Entity
(see page 13 of the instructions)
(b) Transaction
date

(c) Type of transaction
1—Listed
2—Subsequently listed
3—Confidential
4—Contractual protection

(d) Description of transaction

1

2

3

4

5
(e) Did the tax-exempt entity know or
have reason to know this transaction
was a PTST when entered? Answer
Yes or No

(f) Net income attributable to the PTST

(g) 75% of proceeds attributable to the
PTST

(h) Tax imposed on the tax-exempt
entity (see page 13 of the instructions)

Total—column (h). Enter here and on page 1, Part I, line 9
Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 7 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Part II

Page

7

Tax Imposed on Entity Managers (Section 4965) Continued

(a) Name of entity manager

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(b) Transaction number from Part I,
col. (a)

(c) Tax—enter $20,000 for each
transaction listed in col. (b) for each
manager in col. (a)

(d) Manager’s total tax
liability (add amounts in
col. (c))

SCHEDULE K—Taxes on Taxable Distributions of Sponsoring Organizations Maintaining Donor
Advised Funds (Section 4966) (see the instructions)
Part I

Taxable Distributions and Tax Computation

(a)
Item number

(b) Name of sponsoring organization and
donor advised fund

(c) Description of distribution

1
2

3

4

(d) Date of distribution

(e) Amount of distribution

(f) Tax imposed on
organization (20% of
col. (e))

(g) Tax on fund managers
(lesser of 5% of col. (e) or
$10,000)

Total—column (f). Enter here and on page 1, Part I, line 10
Total—column (g). Enter total (or prorated amount) here and in Part II, column (c), below

Part II

Summary of Tax Liability of Fund Managers and Proration of Payments

(a) Name of
fund managers
liable for tax

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

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

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

Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 8 of 10
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Page

8

SCHEDULE L—Taxes on Prohibited Benefits Distributed From Donor Advised Funds (Section 4967)
(see instructions)
Part I
(a) Item
number

(b) Date of prohibited benefit

1

2

3

4

5
(d) Amount of prohibited benefit

Part II

(c) Description of benefit

(e) Tax on prohibited benefit (125% of col. (d)) (see
instructions)

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

Summary of Tax Liability of Donors, Donor Advisors, Related Persons and Proration of Payments

(a) Names of donors, donor advisor, or
related persons liable for tax

Part III

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Prohibited Benefits and Tax Computation

(b) Investment no.
from Part I

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

(d) Donor, donor advisor, or related
persons total tax liability (add amounts in
col. (c)) (see instructions)

Tax Liability of Fund Managers and Proration of Payments

(a) Names of fund managers liable for tax

(b) Investment no.
from Part I

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

(d) Fund managers total tax liability (add
amounts in col. (c)) (see instructions)

Form

4720

(2006)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 4720, PAGE 9 of 10 (PAGE 10 IS BLANK)
MARGINS: TOP 13mm (1⁄ 2 ”), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄ 2 ”) x 838mm (33”), TOP FOLD TO: 216mm (81⁄ 2 ”) x 279mm (11”)
PERFORATE: HORIZONTALLY ON FOLD

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

Form 4720 (2006)

Page

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9

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 or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor advisor,
or related person

Date

Signature (and organization or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor advisor,
or related person

Date

Signature (and organization or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor advisor,
or related person

Date

Signature (and organization or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor advisor,
or related person

Date

Signature of individual or firm preparing the return

Date

(
Address of preparer

)
Phone number of preparer
Form

4720

(2006)