Form 4720 Return of Certain Excise Taxes on Charities and Other Pe

Form

4720

Department of the Treasury
Internal Revenue Service

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

OMB No. 1545-0052

(Sections 170(f)(10), 664(c)(2), 4911, 4912, 4941, 4942, 4943, 4944, 4945, 4955, 4958, 4959, 4965, 4966, and 4967)
▶ Information about Form 4720 and its separate instructions is at www.irs.gov/form4720.

For calendar year 2012 or other tax year beginning

, 2012, and ending

2012

, 20

Name of organization or entity

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

Yes No

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 instructions).

Part I
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Taxes on Organization (Sections 170(f)(10), 664(c)(2), 4911(a), 4912(a), 4942(a), 4943(a), 4944(a)(1),
4945(a)(1), 4955(a)(1), 4959, 4965(a)(1), and 4966(a)(1))
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 (f) . . . . . . . . . .
Tax on a charitable remainder trust’s unrelated business taxable income. Attach schedule
Tax on failure to meet the requirements of section 501(r)(3)-Schedule M, Part II, line 2
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Total (add lines 1–12) . . . . . . . . . . . . . . . . . . . . . . .

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Part II-A Taxes on Managers, Self-Dealers, 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))
(a) Name and address of person subject to tax

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

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

(b) Taxpayer identification number

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

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

a
b
c
Total
(h) Tax on excess benefit
(i) Tax on being a party to prohibited
(g) Tax on disqualifying lobbying
transactions—Schedule I, Part II, col. tax shelter transactions—Schedule J,
expenditures—Schedule H, Part II, col. (d)
(d), and Part III, col. (d)
Part II, col. (d)

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

a
b
c
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
Total
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 13021D

Form 4720 (2012)

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Form 4720 (2012)

Part II-B Summary of Taxes (See Tax Payments in the instructions.)
1

Enter the taxes listed in Part II-A, column (l), that apply to managers, self-dealers, 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) . . . . . . . . . . . . . . . . . .

2
3
4
5

Total tax. Add Part I, line 13, and Part II-B, line 1. . . . . . . . . . . .
Total payments including amount paid with Form 8868 (see instructions) . . . .
Tax due. If line 2 is larger than line 3, enter amount owed (see instructions) . . .
Overpayment. If line 2 is smaller than line 3, enter the difference. This is your refund

Part I
(a) Act
number

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SCHEDULE A—Initial Taxes on Self-Dealing (Section 4941)
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 $20,000 or 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
(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 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 instructions)

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

SCHEDULE B—Initial Tax on Undistributed Income (Section 4942)
1
2
3
4

Undistributed income for years before 2011 (from Form 990-PF for 2012, Part XIII, line 6d) .
Undistributed income for 2011 (from Form 990-PF for 2012, Part XIII, line 6e) . . . . .
Total undistributed income at end of current tax year beginning in 2012 and subject to tax
under section 4942 (add lines 1 and 2) . . . . . . . . . . . . . . . . . .
Tax—Enter 30% of line 3 here and on Part I, line 1 . . . . . . . . . . . . . .

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2
3
4
Form 4720 (2012)

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Form 4720 (2012)

SCHEDULE C—Initial Tax on Excess Business Holdings (Section 4943)
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 for each line item before making any entries.
Name and address of business enterprise

Employer identification number .

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Form of enterprise (corporation, partnership, trust, joint venture, sole proprietorship, etc.) .

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(a)
Voting stock
(profits interest or
beneficial interest)

(b)
Value

(c)
Nonvoting stock
(capital interest)

1

Foundation holdings in business enterprise .

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%

%

2

Permitted holdings in business enterprise

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

3

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

6

5

6
7

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4
5

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

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

Part II

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

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

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

(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 instructions)

Form 4720 (2012)

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Form 4720 (2012)

Part I
(a) Item
number

SCHEDULE E—Initial Taxes on Taxable Expenditures (Section 4945)
Expenditures and Computation of Tax
(b) Amount

(c) Date paid
or incurred

(d) Name and address of recipient

(e) Description of expenditure and purposes
for which made

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

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

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
Part I, line 4 . . . . . . . . . .
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
(b) Item no. from
Part I, col. (a)

(a) Names of foundation managers liable for tax

Part I
(a) Item
number

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

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

SCHEDULE F—Initial Taxes on Political Expenditures (Section 4955)
Expenditures and Computation of Tax
(b) Amount

(c) Date paid
or incurred

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

(d) Description of political expenditure

(f) Initial tax imposed on
managers (if applicable) (lesser
of $5,000 or 2½% of col. (b))

1
2
3
4
5
Total— column (e). Enter here and on Part I, line 5

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

Part II

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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

(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 instructions)

Form 4720 (2012)

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Form 4720 (2012)

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

Excess of grassroots expenditures over grassroots nontaxable amount (from Schedule C (Form
990 or 990-EZ), Part II-A, column (b), line 1h). (See the instructions before making an entry.) . .

1

Excess of lobbying expenditures over lobbying nontaxable amount (from Schedule C (Form 990 or
990-EZ), Part II-A, column (b), line 1i). (See the instructions before making an entry.) . . . . .

2

3

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

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

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Part I
(a) Item
number

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

(c) Date paid or
incurred

(d) Description of lobbying expenditures

(e) Tax imposed on organization
(5% of col. (b))

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

1
2
3
4
5
Total— column (e). Enter here and on Part I, line 7

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

Part II

(a) Names of organization managers liable for tax

Part I
(a)
Transaction
number

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Summary of Tax Liability of Organization Managers and Proration of Payments
(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 instructions)

SCHEDULE I—Initial Taxes on Excess Benefit Transactions (Section 4958)
Excess Benefit Transactions and Tax Computation
(b) Date of transaction

(c) Description of transaction

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2
3
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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
$20,000 or 10% of col. (d))

Form 4720 (2012)

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Form 4720 (2012)

Part II

SCHEDULE I—Initial Taxes on Excess Benefit Transactions (Section 4958) Continued
Summary of Tax Liability of Disqualified Persons and Proration of Payments
(b) Trans. no. from
Part I, col. (a)

(a) Names of disqualified persons liable for tax

Part III

Summary of Tax Liability of 501(c)(3), (c)(4) & (c)(29) Organization Managers and Proration of Payments

(a) Names of 501(c)(3), (c)(4) & (c)(29) organization managers liable for tax

Part I

(a)
Transaction
number

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

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

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

(d) Manager’s total tax liability
(add amounts in col. (c))
(see 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)
Prohibited Tax Shelter Transactions (PTST) and Tax Imposed on the Tax-Exempt Entity
(see 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 it became a party to
the transaction? Answer Yes or No

(f) Net income attributable to
the PTST

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

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(g) 75% of proceeds attributable to
the PTST

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

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Form 4720 (2012)

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Form 4720 (2012)

Part II

Tax Imposed on Entity Managers (Section 4965) Continued
(a) Name of entity manager

Part I

(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.
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

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

(e) Amount of distribution

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

Part II

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

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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 (2012)

Page 8

Form 4720 (2012)

SCHEDULE L—Taxes on Prohibited Benefits Distributed From Donor Advised Funds (Section 4967).
See the instructions.
Part I
Prohibited Benefits and Tax Computation
(a) Item
number

(b) Date of
prohibited benefit

(c) Description of benefit

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

Part II

(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

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

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

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

(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 (2012)

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Form 4720 (2012)

Part I
(a) Item
number

Schedule M—Tax on Failure to Meet the Community Health Needs Assessment
Requirements (Section 501(r)(3)). (See instructions.)
Name of Hospital Facility and Summary of Failure to Meet Section 501(r)(3)
(b) Name of facility

(d) Tax year hospital
facility last conducted a
CHNA

(c) Description of the failure

(e) Tax year hospital
facility last adopted an
implementation strategy

1
2
3
4
5

Part II

Computation of Tax

1

Number of hospital facilities operated by the hospital organization that failed to meet the Community
Health Needs Assessment requirements of section 501(r)(3) . . . . . . . . . . . . . .

2

Tax—Enter $50,000 multiplied by line 1 here and on Part I, line 12 .

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Form 4720 (2012)

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Form 4720 (2012)

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.

▲
▲
▲

Sign
Here

Title

Signature of officer or trustee

▲
▲

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

May the IRS discuss this return with the preparer shown below? (see instructions)

Paid
Preparer
Use Only

Date

Print/Type preparer’s name

Firm’s name

▶

Firm’s address ▶

Preparer’s signature

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Date

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No

Yes

Check
if
self-employed

PTIN

Firm's EIN ▶
Phone no.

Form 4720 (2012)