Part II-B

Part II-A

Return of Certain Excise Taxes on Charities

and Other Persons Under Chapters 41 and

42 of the Internal Revenue Code

OMB No. 1545-0052

Form 4720

Department of the Treasury (Sections 170(f)(10), 4911, 4912, 4941, 4942, 4943, 4944, 4945, 4955, and 4958) Internal Revenue Service  See separate instructions.

For calendar year 2003 or other tax year beginning 2003, and ending 20

Name of foundation or public charity 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 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),

and 4955(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

9 Total (add lines 1–8) 9

Taxes on Self-Dealers, Disqualified Persons, Foundation Managers, and Organization Managers

(Sections 4912(b), 4941(a), 4944(a)(2), 4945(a)(2), 4955(a)(2), and 4958(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),

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

(i) Total—Add cols. (c) through (h) (g) Tax on disqualifying lobbying expenditures—

Schedule H, Part II, col. (d)

a

b

c

d

Total

Summary of Taxes (See Tax Payments on page 2 of the instructions.)

Enter the taxes listed in Part II-A, column (i), that apply to self-dealers, disqualified persons,

foundation managers, and organization managers who sign this form. If all sign, enter the

total amount from Part II-A, column (i)

1

1

2 Total tax. Add Part I, line 9, and Part II-B, line 1. (Make check(s) or money order(s) payable

to the United States Treasury.) 2

For Paperwork Reduction Act Notice, see page 8 of the instructions. Form 4720 (2003)

Part I

Cat. No. 13021D

(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

2003
Form 4720 (2003) 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

$10,000 or 21⁄2% 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

(5% 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 4 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 4 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 2002 (from Form 990-PF for 2003, Part XIII, line 6d) 1

2 Undistributed income for 2002 (from Form 990-PF for 2003, Part XIII, line 6e) 2

Total undistributed income at end of current tax year beginning in 2003 and subject to tax

under section 4942 (add lines 1 and 2)

3

3

4 Tax—Enter 15% of line 3 here and on page 1, Part I, line 1 4

Part I

Part II

Part III

Form 4720 (2003)
Form 4720 (2003) 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 4 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 5% 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

(5% of col. (d))

(f) Initial tax on foundation

managers (if applicable)—

(lesser of $5,000 or 5% 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 6 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 (2003)
Form 4720 (2003) 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

(10% 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 $5,000 or 21⁄2% 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 7 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 7 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 (2003)
Form 4720 (2003) 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

2 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

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 7 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

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

(e) Initial tax on disqualified persons

(25% of col. (d))

Part I

Form 4720 (2003)
Form 4720 (2003) Page 6

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

Date

Date

Signature of individual or firm preparing the return Date

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 8 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 8 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

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

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

Form 4720 (2003)

Address of preparer Phone number of preparer

( )

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