4720 Return of Certain Excise Taxes Under Chapters 41 and 42

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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. 1545-0047

2021

(Sections 170(f)(10), 664(c)(2), 4911, 4912, 4941, 4942, 4943, 4944,
4945, 4955, 4958, 4959, 4960, 4965, 4966, 4967, and 4968)
▶ Go to www.irs.gov/Form4720 for instructions and the latest information.

For calendar year 2021 or other tax year beginning

, 2021, and ending

, 20
EIN or SSN

Name of organization, entity, or person subject to tax

DRAFT AS OF
September 21, 2021
DO NOT FILE
Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)

Amended return

Check box for type of annual return:

City or town, state or province, country, and ZIP or foreign postal code

Form 990

Form 990-EZ

Form 990-PF

Other

Form 5227

A

B

Yes No
Is the organization a foreign private foundation within the meaning of section 4948(b)? . . . . . . . . .
Show conversion rate to U.S. dollars. See instructions . . . . . . . . . . ▶
Entity (other than the organization) or person subject to tax: Are you required to file Form 4720 with respect to
more than one organization in the current tax year? See instructions . . . . . . . . . . . . . . .
If “Yes,” attach a list showing the name and EIN for each organization with respect to which you will file Form 4720 for the
current tax year.

Part I

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14
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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, 4960(a), 4965(a)(1), 4966(a)(1), and 4968(a))

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 (f) .
Tax on taxable expenditures—Schedule E, Part I, column (h) . . . . . . . . . .
Tax on political expenditures—Schedule F, Part I, column (f) . . . . . . . . . .
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 statement
Tax on failure to meet the requirements of section 501(r)(3)—Schedule M, Part II, line 2 .
Tax on excess executive compensation—Schedule N . . . . . . . . . . . .
Tax on net investment income of private colleges and universities—Schedule O . . .
Total (add lines 1–14) . . . . . . . . . . . . . . . . . . . . . . .

Part II

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Taxes on a Manager, Self-Dealer, Disqualified Person, Donor, Donor Advisor, or Related Person
(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))

Name and address of related organization; city or town, state or province, country, ZIP or foreign postal code Employer identification number
1
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9
10

Tax on self-dealing—Schedule A, Part II, column (d); and Part III, column (d) . . . . .
Tax on investments that jeopardize charitable purposes—Schedule D, Part II, column (d)
Tax on taxable expenditures—Schedule E, Part II, column (d) . . . . . . . . . .
Tax on political expenditures—Schedule F, Part II, column (d) . . . . . . . . .
Tax on disqualifying lobbying expenditures—Schedule H, Part II, column (d) . . . . .
Tax on excess benefit transactions—Schedule I, Part II, column (d); and Part III, column (d)
Tax on being a party to prohibited tax shelter transactions—Schedule J, Part II, column (d)
Tax on taxable distributions—Schedule K, Part II, column (d) . . . . . . . . . .
Tax on prohibited benefits—Schedule L, Part II, column (d); and Part III, column (d) . .
Total—Add lines 1 through 9 . . . . . . . . . . . . . . . . . . . .

Part III
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Tax Payments

Total tax (Part I, line 15 or Part II, line 10) . . . . . . . . . . . . . .
Total payments including amount paid with Form 8868 (see instructions) . . . .
Tax due. If line 1 is larger than line 2, enter amount owed (see instructions) . . .
Overpayment. If line 1 is smaller than line 2, enter the difference. This is your refund

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

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Cat. No. 13021D

Form 4720 (2021)

Page 2

Form 4720 (2021)

Part I
(a) Act
number

SCHEDULE A—Initial Taxes on Self-Dealing (Section 4941)
Acts of Self-Dealing and Tax Computation
(b) Date of act

(c) Correction made?
Yes

(d) Description of act

No

1
2
3
4
5

DRAFT AS OF
September 21, 2021
DO NOT FILE
(e) Question number from
Form 990-PF, Part VI-B,
or Form 5227, Part VIII,
applicable to the act

Part II

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

Part III

(h) Tax on foundation managers
(if applicable)
(lesser of $20,000 or 5% of col. (f))

(g) Initial tax on self-dealer
(10% of col. (f))

(f) Amount involved in act

(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. (g),
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. (h),
or prorated amount

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

Undistributed income for years before 2020 (from Form 990-PF for 2021, Part XII, line 6d)
Undistributed income for 2020 (from Form 990-PF for 2021, Part XII, line 6e)
. . . .
Total undistributed income at end of current tax year beginning in 2021 and subject to
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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Form 4720 (2021)

Page 3

Form 4720 (2021)

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

DRAFT AS OF
September 21, 2021
DO NOT FILE
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)

(c)
Nonvoting stock
(capital interest)

(b)
Value

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Foundation holdings in business enterprise .

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%

2

Permitted holdings in business enterprise

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%

3

Value of excess holdings in business enterprise

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Value of excess holdings disposed of within 90
days; or, other value of excess holdings not subject
to section 4943 tax (attach statement)
. . . .
Taxable excess holdings in business enterpriseline 3 minus line 4 . . . . . . . . . . .

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5

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7

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

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7
Yes No

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Did the organization dispose of excess holdings subject to tax reported on line 6? . . . . . . . .
Attach a statement explaining (i) corrective action taken, or (ii) why corrective action has not been taken.

Part I
(a)
Investment
number

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SCHEDULE D—Initial Taxes on Investments That Jeopardize Charitable Purpose (Section 4944)
Investments and Tax Computation
(b) Date of
investment

(c) Correction
made?
Yes

(d) Description of investment

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

(e) Amount of
investment

No

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

Part II

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

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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. (g),
or prorated amount

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

Form 4720 (2021)

Page 4

Form 4720 (2021)

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) Correction made?
Yes

(e) Name and address of recipient

No

1
2
3
4
5

DRAFT AS OF
September 21, 2021
DO NOT FILE
(f) Description of expenditure and purposes for which made

(g) Question number from
Form 990-PF, Part VI-B,
or Form 5227, Part VIII,
applicable to the
expenditure

Total—Column (h). Enter here and on Part I, line 4 . . . . . . . . . . . . . .
Total—Column (i). Enter total (or prorated amount) here and in Part II, column (c), below .

Part II

(a) Item
number

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

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

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

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

(c) Date paid
or incurred

(d) Correction
made?
Yes

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

(e) Description of political expenditure

No

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5
Total—Column (f). Enter here and on Part I, line 5 . . . . . . . . . . . . . .
Total—Column (g). Enter total (or prorated amount) here and in Part II, column (c), below .

Part II

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Summary of Tax Liability of Foundation Managers and Proration of Payments

(a) Names of foundation managers liable for tax

Part I

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

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

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

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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. (g),
or prorated amount

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

Form 4720 (2021)

Page 5

Form 4720 (2021)

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

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

1

DRAFT AS OF
September 21, 2021
DO NOT FILE
2

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

2

3

Excess 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

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Total—Column (e). Enter here and on Part I, line 7 . . . . . . . . . . . . . .
Total—Column (f). Enter total (or prorated amount) here and in Part II, column (c), below .

Part II

(a)
Transaction
number

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

Part I

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

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

(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) Correction made?
Yes

No

(d) Description of transaction

1
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(e) Amount of excess benefit

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

(g) Tax on organization managers
(if applicable)
(lesser of $20,000 or 10% of col. (e))

Form 4720 (2021)

Page 6

Form 4720 (2021)

SCHEDULE I—Initial Taxes on Excess Benefit Transactions (Section 4958) Continued
Summary of Tax Liability of Disqualified Persons and Proration of Payments

Part II

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

(a) Names of disqualified persons liable for tax

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

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

DRAFT AS OF
September 21, 2021
DO NOT FILE
Part III

Summary of Tax Liability of 501(c)(3), (c)(4) & (c)(29) Organization Managers and Proration of Payments
(b) Trans. no.
from Part I,
col. (a)

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

Part I
(a)
Transaction
number

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

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

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
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(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?
Yes

(f) Net income attributable
to the PTST

(g) 75% of proceeds attributable
to the PTST

No

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

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

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Form 4720 (2021)

Page 7

Form 4720 (2021)

Part II

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

(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))

DRAFT AS OF
September 21, 2021
DO NOT FILE
Part I

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 (2021)

Page 8

Form 4720 (2021)

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

DRAFT AS OF
September 21, 2021
DO NOT FILE
1
2
3
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(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 advisors, or
related persons liable for tax

Part III

(e) Tax on donors, donor advisors, or related persons
(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’s, donor advisor’s, or
related person’s total tax liability
(add amounts in col. (c))
(see instructions)

Summary of 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 manager’s total tax liability
(add amounts in col. (c))
(see instructions)

Form 4720 (2021)

Page 9

Form 4720 (2021)

Part I

Schedule M—Tax on Hospital Organization for Failure to Meet the Community Health Needs
Assessment Requirements (Sections 4959 and 501(r)(3)). (See instructions.)
Failures to Meet Section 501(r)(3)

(a) Item
number

(b) Name of hospital 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

DRAFT AS OF
September 21, 2021
DO NOT FILE
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Part II
1

Computation of Tax

Number of hospital facilities operated by the hospital organization that failed to meet the Community
Health Needs Assessment requirements of section 501(r)(3) . . . . . . . . . . . . .
Tax—Enter $50,000 multiplied by line 1 here and on Part I, line 12 . . . . . . . . . . .

2

1
2

SCHEDULE N—Tax on Excess Executive Compensation (Section 4960). (See instructions.)

(a) Item
number

(b) Name of covered employee

(d) Excess parachute
payment

(c) Excess remuneration

1
2
3
4
5
6
Attachment, if necessary. See instructions . . . . .
Total (add column (e) items 1–6)
. . . . . . . . . .
Tax. Enter 21% of the amount above here and on Part I, line 13

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(e) Total.
Add column (c) and (d)

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SCHEDULE O—Excise Tax on Net Investment Income of Private Colleges and Universities (Section 4968)
(a) Name

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(c) Gross
investment income
(See instructions.)

(b) EIN

(d) Capital gain
net income

(e) Administrative
expenses allocable
to income included
in cols. (c) and (d)

(f) Net investment
income
(See instructions.)

Filing
Organization
Related
Organization
Related
Organization
Related
Organization

5

Total from attachment, if necessary

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6

Total

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Excise Tax on Net Investment Income. Enter 1.4% of the amount in 6(f) here and on Part I, line 14

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Form 4720 (2021)

Page 10

Form 4720 (2021)

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.

▲

DRAFT AS OF
September 21, 2021
DO NOT FILE
Sign
Here

Title

Signature of officer or trustee

▲

Date

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

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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Yes

Check
if
self-employed

PTIN

No

Firm’s EIN ▶
Phone no.

Form 4720 (2021)