Part II-A

Return of Certain Excise Taxes Under Chapters

41 and 42 of the Internal Revenue Code

OMB No. 1545-0052

Form 4720

(Sections 170(f)(10), 664(c)(2), 4911, 4912, 4941, 4942, 4943, 4944, 4945, 4955, 4958, 4965, 4966, and 4967) Department of the Treasury

Internal Revenue Service See separate instructions.

For calendar year 2009 or other tax year beginning , 2009, and ending , 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 Form 990-EZ

City or town, state, and ZIP code Form 990-PF

Form 5227

Yes No

A 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)

B

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 4 of the instructions).

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), 4965(a)(1), and 4966(a)(1))

1 Tax on undistributed income—Schedule B, line 4 1

2 Tax on excess business holdings—Schedule C, line 7 2

3 Tax on investments that jeopardize charitable purpose—Schedule D, Part I, column (e) 3

4 Tax on taxable expenditures—Schedule E, Part I, column (g) 4

5 Tax on political expenditures—Schedule F, Part I, column (e) 5

6 Tax on excess lobbying expenditures—Schedule G, line 4 6

7 Tax on disqualifying lobbying expenditures—Schedule H, Part I, column (e) 7

12 Total (add lines 1–11)

11

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 (b) Taxpayer identification number

a

b

c

d

(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)

(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

d

Total

(j) Tax on taxable distributions—

Schedule K, Part II, col. (d)

(g) Tax on disqualifying lobbying

expenditures—Schedule H, Part II, col. (d)

a

b

c

d

Total

Part I

(h) Tax on excess benefit

transactions—Schedule I, Part II, col.

(d), and Part III, col. (d)

8 Tax on premiums paid on personal benefit contracts 8

9 Tax on being a party to prohibited tax shelter transactions—Schedule J, Part I, column (h) 9

(i) Tax on being a party to prohibited

tax shelter transactions—Schedule J,

Part II, col. (d)

10 Tax on taxable distributions—Schedule K, Part I, column (f) 10

(l) Total—Add cols. (c) through (k) (k) Tax on prohibited benefits—Sch L,

Part II, col. (d), and Part III, col. (d)

a

b

c

d

Total

11 Tax on a charitable remainder trust’s unrelated business taxable income. Attach schedule

12

2009
Form 4720 (2009) Page 2

SCHEDULE A—Initial Taxes on Self-Dealing (Section 4941)

Acts of Self-Dealing and Tax Computation

(b) Date

of act

(a) Act

number (c) Description of act

1

2

3

4

5

(g) Tax on foundation managers (if

applicable) (lesser of $20,000 or 5% of

col. (e))

(d) Question number from Form 990-PF,

Part VII-B, or Form 5227, Part VI-B,

applicable to the act

(f) Initial tax on self-dealing

(10% of col. (e)) (e) Amount involved in act

Summary of Tax Liability of Self-Dealers and Proration of Payments

(d) Self-dealer’s total tax

liability (add amounts in col. (c))

(see page 6 of the instructions)

(b) Act no. from

Part I, col. (a)

(c) Tax from Part I, col. (f),

or prorated amount (a) Names of self-dealers liable for tax

Summary of Tax Liability of Foundation Managers and Proration of Payments

(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

(b) Act no. from

Part I, col. (a) (a) Names of foundation managers liable for tax

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

1 Undistributed income for years before 2008 (from Form 990-PF for 2009, Part XIII, line 6d) 1

2 Undistributed income for 2008 (from Form 990-PF for 2009, Part XIII, line 6e) 2

Total undistributed income at end of current tax year beginning in 2009 and subject to tax

under section 4942 (add lines 1 and 2)

3

3

4 Tax—Enter 30% of line 3 here and on page 1, Part I, line 1 4

Part I

Part II

Part III

Form 4720 (2009)

Part II-B Summary of Taxes (See Tax Payments on page 3 of the instructions.)

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)

1

1

2 Total tax. Add Part I, line 12, and Part II-B, line 1. (Make check(s) or money order(s) payable

to the United States Treasury.) 2
Form 4720 (2009) Page 3

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 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 Value of excess holdings in business enterprise 3

Value of excess holdings disposed of within 90

days; or, other value of excess holdings not

subject to section 4943 tax (attach explanation)

4

4

5 Taxable excess holdings in business enterprise—

line 3 minus line 4 5

6 Tax—Enter 10% of line 5 6

Total tax—Add amounts on line 6, columns (a), (b),

and (c); enter total here and on page 1, Part I, line 2

7

7

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

Investments and Tax Computation

(e) Initial tax on

foundation (10% of

col. (d))

(f) Initial tax on foundation

managers (if applicable)—

(lesser of $10,000 or 10%

of col. (d))

(d) Amount of

investment

(b) Date of

investment

(a) Investment

number (c) Description of investment

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

Summary of Tax Liability of Foundation Managers and Proration of Payments

(d) Manager’s total tax

liability (add amounts in col.

(c)) (see page 10 of the

instructions)

(c) Tax from Part I, col. (f),

or prorated amount

(b) Investment

no. from Part I,

col. (a)

(a) Names of foundation managers liable for tax

Part I

Part II

Form 4720 (2009)
Form 4720 (2009) Page 4

SCHEDULE E—Initial Taxes on Taxable Expenditures (Section 4945)

Expenditures and Computation of Tax

(e) Description of expenditure and purposes

for which made

(c) Date paid

or incurred

(a) Item

number

(b) Amount (d) Name and address of recipient

1

2

3

4

5

(g) Initial tax imposed on foundation

(20% of col. (b))

(f) Question number from Form 990-PF, Part VII-B, or

Form 5227, Part VI-B, applicable to the expenditure

(h) Initial tax imposed on foundation

managers (if applicable)—(lesser of

$10,000 or 5% of col. (b))

Total—column (g). Enter here and on

page 1, Part I, line 4

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

below 

Summary of Tax Liability of Foundation Managers and Proration of Payments

(d) Manager’s total tax liability

(add amounts in col. (c))

(see page 10 of the instructions)

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

prorated amount

(b) Item no. from

Part I, col. (a)

(a) Names of foundation managers liable for tax

SCHEDULE F—Initial Taxes on Political Expenditures (Section 4955)

Expenditures and Computation of Tax

(f) Initial tax imposed on

managers (if applicable) (lesser

of $5,000 or 21⁄2% of col. (b))

(e) Initial tax imposed on

organization or foundation

(10% of col. (b))

(c) Date paid

or incurred

(a) Item

number

(b) Amount (d) Description of political expenditure

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

Summary of Tax Liability of Organization Managers or Foundation Managers and Proration of Payments

(d) Manager’s total tax liability

(add amounts in col. (c))

(see page 11 of the instructions)

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

prorated amount

(b) Item no. from

Part I, col. (a)

(a) Names of organization managers or

foundation managers liable for tax

Part I

Part II

Part I

Part II

Form 4720 (2009)
Form 4720 (2009) Page 5

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 page 11 of the instructions before making

entry.) 1

2 Excess of lobbying expenditures over lobbying nontaxable amount (from Schedule C (Form 990

or 990-EZ), Part II-A, column (b), line 1i). (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

SCHEDULE H—Taxes on Disqualifying Lobbying Expenditures (Section 4912)

Expenditures and Computation of Tax

(f) Tax imposed on organization

managers (if applicable)—

(5% of col. (b))

(c) Date paid

or incurred

(a) Item

number

(e) Tax imposed on organization

(5% of col. (b))

(b) Amount (d) Description of lobbying expenditures

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

Summary of Tax Liability of Organization Managers and Proration of Payments

(d) Manager’s total tax liability

(add amounts in col. (c))

(see page 11 of the instructions)

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

prorated amount

(b) Item no. from

Part I, col. (a)

(a) Names of organization managers liable for tax

Part I

Part II

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

Excess Benefit Transactions and Tax Computation

(b) Date of

transaction

(a)

Transaction

number

(c) Description of transaction

1

2

3

4

5

(d) Amount of excess benefit (f) Tax on organization managers

(if applicable) (lesser of

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

(e) Initial tax on disqualified persons

(25% of col. (d))

Part I

Form 4720 (2009)
Form 4720 (2009) Page 6

Summary of Tax Liability of Disqualified Persons and Proration of Payments

(d) Disqualified person’s total tax

liability (add amounts in col. (c)) (see

page 13 of the instructions)

(b) Trans. no. from

Part I, col. (a)

(c) Tax from Part I, col. (e),

or prorated amount (a) Names of disqualified persons liable for tax

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

(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

(b) Trans. no. from

Part I, col. (a) (a) Names of 501(c)(3) & (4) organization managers liable for tax

Part II

Part III

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

Prohibited Tax Shelter Transactions (PTST) and Tax Imposed on the Tax-Exempt Entity

(see page 13 of the instructions)

(d) Description of transaction

(b) Transaction

date

(c) Type of transaction

1—Listed

2—Subsequently listed

3—Confidential

4—Contractual protection

(a)

Transaction

number

Part I

SCHEDULE J—Taxes on Being a Party to Prohibited Tax Shelter Transactions (Section 4965)

Form 4720 (2009)

1

2

3

4

5

(h) Tax imposed on the tax-exempt

entity (see page 14 of the instructions)

(g) 75% of proceeds attributable to

the PTST

(f) Net income attributable to

the PTST

(e) Did the tax-exempt entity know or

have reason to know this transaction

was a PTST when it became a party to

the trans.? Answer Yes or No

Total—column (h). Enter here and on page 1, Part I, line 9
Form 4720 (2009) Page 7

Tax Imposed on Entity Managers (Section 4965) Continued

(d) Manager’s total tax liability

(add amounts in col. (c))

(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)

(a) Name of entity manager

Part II

SCHEDULE K—Taxes on Taxable Distributions of Sponsoring Organizations Maintaining Donor

Advised Funds (Section 4966). See page 14 of the instructions.

Taxable Distributions and Tax Computation

(d) Date of distribution

(b) Name of sponsoring organization and

donor advised fund

(a) (c) Description of distribution

Item number

Part I

1

2

3

4

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

(f) Tax imposed on

organization (20% of

col. (e))

(g) Tax on fund managers

(lesser of 5% of col. (e) or

$10,000)

(e) Amount of distribution

Form 4720 (2009)

Summary of Tax Liability of Fund Managers and Proration of Payments

(d) Manager’s total tax liability

(add amounts in col. (c)) 

(see instructions)

(b) Item no. from

Part I, col. (a)

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

amount

(a) Name of fund managers liable for tax

Part II
Form 4720 (2009) Page 8

SCHEDULE L—Taxes on Prohibited Benefits Distributed From Donor Advised Funds (Section 4967).

See page 14 of the instructions.

Prohibited Benefits and Tax Computation

(d) Amount of prohibited benefit

(b) Date of

prohibited benefit (c) Description of benefit (a) Itemnumber

Part I

1

2

3

4

(f) Tax on fund managers (if applicable) (lesser of 10% of col.

(d) or $10,000) (see instructions)

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

(see instructions)

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

(d) Donor, donor advisor, or related persons total tax

liability (add amounts in col. (c)) (see instructions)

(b) Item no. from

Part I, col. (a)

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

prorated amount

(a) Names of donors, donor advisor, or

related persons liable for tax

Part II

5

Tax Liability of Fund Managers and Proration of Payments

(d) Fund managers total tax liability (add

amounts in col. (c)) (see instructions)

(b) Item no. from

Part I, col. (a)

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

prorated amount

(a) Names of fund managers liable for tax

Part III

Form 4720 (2009)
Form 4720 (2009) Page 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 Date

advisor, or related person

Date

Date

Form 4720 (2009)

Date

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

advisor, or related person

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

advisor, or related person

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

advisor, or related person

Date Preparer’s SSN or PTIN

Preparer’s

signature Paid

Preparer’s

Use Only Firm’s name (or

yours if self-employed),

address, and ZIP code

Phone no. ( )



EIN

Check

if selfemployed

Sign

Here