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 4911, 4912, 4941, 4942, 4943, 4944, 4945, and 4955)

Internal Revenue Service © See separate instructions.

For the calendar year 1991 or other tax year beginning , 1991, and ending , 19 .

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 990EZ

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 transaction that resulted in Chapter 42 taxes being reported on this

form?

B

If “Yes,” attach a detailed documentation and description of the corrective action taken and, if applicable, enter the fair market value of any

property recovered as a result of the correction © $ . For any uncorrected acts, attach explanation (see instructions).

Taxes on Private Foundation or Public Charity (Sections 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

8 Total (add lines 1–7) 8

Taxes on Self-dealers, Foundation Managers, and Organization Managers (Sections 4912(b),

4941(a), 4944(a)(2), 4945(a)(2), and 4955(a)(2))

(b) Taxpayer

identifying 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

(g) Tax on disqualifying lobbying expenditures—Schedule H, Part II, col. (d) (h) Total—Add cols. (c) through (g)

a

b

c

d

Total

Summary of Taxes (See General Instructions on Tax Payments)

Enter the total taxes listed in Part II-A, column (h), that apply to foundation managers,

self-dealers, and organization managers who sign this form. If all sign, enter the total amount

from Part II-A, column (h). 

1

1

2 Total tax. Add Part I, line 8, and Part II-B, line 1. (Make check or money order payable to

the Internal Revenue Service.) 2

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 4720 (1991)

Part I

Cat. No. 13021D
Form 4720 (1991) 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, or Form 5227, Part VI,

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 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 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 1990 (from Form 990-PF for 1991, Part XIII, line 6d):

a Enter year 1a

b Enter year 1b

c Enter year 1c

2 Undistributed income for 1990 (from Form 990-PF for 1991, Part XIII, line 6e) 2

Total undistributed income at end of current tax year beginning in 1991 and subject to tax

under section 4942 (add lines 1a, b, c, 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 (1991) 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 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 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 (1991) 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, or

Form 5227, Part VI, 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 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 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 (1991) Page 5

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

1 Excess of grass roots expenditures over grass roots nontaxable amount (from Schedule A (Form

990), Part VI-A, column (b), line 43). (See instructions before making entry.) 1

2 Excess of lobbying expenditures over lobbying nontaxable amount (from Schedule A (Form 990),

Part VI-A, column (b), line 44). (See 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 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

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, foundation manager, or organization manager Date

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

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

Signature of individual or firm preparing the return Address of preparer Date

Part I

Part II