Form 4720

Department of the Treasury 

Internal Revenue Service 

Return of Certain Excise Taxes Under Chapters 

41 and 42 of the Internal Revenue Code 

(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. 

OMB No. 1545-0052

2012

For calendar year 2012 or other tax year beginning , 2012, 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)

City or town, state, and ZIP code

Check box for type of annual return:

Form 990

Form 990-PF

Form 5227

Form 990-EZ

Yes No

A Is the organization a foreign private foundation within the meaning of section 4948(b)? . . . . . . . . .

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 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))

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 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

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

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

12 Tax on failure to meet the requirements of section 501(r)(3)-Schedule M, Part II, line 2 . . 12

13 Total (add lines 1–12) . . . . . . . . . . . . . . . . . . . . . . . . 13

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 (b) Taxpayer identification number

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)

(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

(g) Tax on disqualifying lobbying 

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

(h) Tax on excess benefit transactions—Schedule I, Part II, col.

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

(i) Tax on being a party to prohibited

tax shelter transactions—Schedule J,

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)
Form 4720 (2012) Page 2

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) . . . . . . . . . . . . . . . . . . 1

2 Total tax. Add Part I, line 13, and Part II-B, line 1. . . . . . . . . . . . . . . 2

3 Total payments including amount paid with Form 8868 (see instructions) . . . . . . . 3

4 Tax due. If line 2 is larger than line 3, enter amount owed (see instructions) . . . . . ▶ 4

5 Overpayment. If line 2 is smaller than line 3, enter the difference. This is your refund . . ▶ 5

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

Part I Acts of Self-Dealing and Tax Computation

(a) Act

number

(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

(e) Amount involved in act (f) Initial tax on self-dealing 

(10% of col. (e))

(g) Tax on foundation managers (if 

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

col. (e))

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

(a) Names of self-dealers liable for tax (b) Act no. from

Part I, col. (a)

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

or prorated amount

(d) Self-dealer’s total tax liability (add amounts in col. (c))

(see instructions)

Part III 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)

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

or prorated amount

(d) Manager’s total tax liability

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

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

1 Undistributed income for years before 2011 (from Form 990-PF for 2012, Part XIII, line 6d) . 1

2 Undistributed income for 2011 (from Form 990-PF for 2012, Part XIII, line 6e) . . . . . 2

3 Total undistributed income at end of current tax year beginning in 2012 and subject to tax 

under section 4942 (add lines 1 and 2) . . . . . . . . . . . . . . . . . . 3

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

Form 4720 (2012)
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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)

(b) 

Value

(c) 

Nonvoting stock

(capital interest)

1 Foundation holdings in business enterprise . . 1 % %

2 Permitted holdings in business enterprise . . 2 % %

3 Value of excess holdings in business enterprise 3

4 

 

Value of excess holdings disposed of within 90 

days; or, other value of excess holdings not 

subject to section 4943 tax (attach explanation) 4

5 Taxable excess holdings in business enterprise— 

line 3 minus line 4 . . . . . . . . . . 5

6 Tax—Enter 10% of line 5 . . . . . . . . 6

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

(b), and (c); enter total here and on Part I, line 2 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 ofinvestment

(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))

1

2

3

4

5

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

Total— column (f). 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

(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)

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

Part I Expenditures and Computation of Tax

(a) Item

number (b) Amount (c) Date paid or incurred (d) Name and address of recipient (e) Description of expenditure and purposesfor which made

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

(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))

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

(a) Names of foundation managers liable for tax (b) Item no. from

Part I, col. (a)

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

prorated amount

(d) Manager’s total tax liability

(add amounts in col. (c))

(see instructions)

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

Part I Expenditures and Computation of Tax

(a) Item

number (b) Amount (c) Date paidor incurred (d) Description of political expenditure

(e) Initial tax imposed on

organization or foundation

(10% of col. (b))

(f) Initial tax imposed on

managers (if applicable) (lesser

of $5,000 or 21⁄2% of col. (b))

1

2

3

4

5

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

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

Part II 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)

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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

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 the instructions before making an 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 Part I, line 6 . . . . . . . . . . . . . . . . 4

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

Part I Expenditures and Computation of Tax

(a) Item

number (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 . . . . . . . .

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

Part II Summary of Tax Liability of Organization Managers and Proration of Payments

(a) Names of organization 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)

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

Part I Excess Benefit Transactions and Tax Computation

(a) 

Transaction

number

(b) Date of transaction (c) Description of transaction

1

2

3

4

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))

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Form 4720 (2012) Page 6

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

Part II Summary of Tax Liability of Disqualified Persons and Proration of Payments

(a) Names of disqualified persons liable for tax (b) Trans. no. from

Part I, col. (a)

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

or prorated amount

(d) Disqualified person’s total tax

liability (add amounts in col. (c))

(see instructions)

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

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

(see instructions)

(a) 

Transaction

number

(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

(g) 75% of proceeds attributable to

the PTST

(h) Tax imposed on the tax-exempt

entity (see instructions)

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

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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))

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

Advised Funds (Section 4966). See the instructions.

Part I 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 (e) Amount of distribution

(f) Tax imposed on

organization (20% of

col. (e))

(g) Tax on fund managers

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

$10,000)

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 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)

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

(see instructions)

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

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

Part II 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

(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)

Part III 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)
Form 4720 (2012) Page 9

Schedule M—Tax on Failure to Meet the Community Health Needs Assessment 

Requirements (Section 501(r)(3)). (See instructions.)

Part I Name of Hospital Facility and Summary of Failure to Meet Section 501(r)(3)

(a) Item 

number (b) Name of facility (c) Description of the failure

(d) Tax year hospital 

facility last conducted a 

CHNA

(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) . . . . . . . . . . . . . . 1

2 Tax—Enter $50,000 multiplied by line 1 here and on Part I, line 12 . . . . . . . . . . . . 2

Form 4720 (2012)
Form 4720 (2012) Page 10

Sign 

Here

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 

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) . . . . . . . . . . . Yes No

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer’s signature Date Check if 

self-employed 

PTIN

Firm’s name ▶

Firm’s address ▶

Firm's EIN ▶

Phone no. 

Form 4720 (2012)