Form 4720

2021

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, 4960, 4965, 4966, 4967, and 4968) Department of the Treasury 

Internal Revenue Service ▶ Go to www.irs.gov/Form4720 for instructions and the latest information.

OMB No. 1545-0047

For calendar year 2021 or other tax year beginning , 2021, and ending , 20

Name of organization, entity, or person subject to tax

Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)

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

EIN or SSN

Amended return

Check box for type of annual return:

Form 990

Form 990-PF

Form 5227

Form 990-EZ

Other

Yes No

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

Show conversion rate to U.S. dollars. See instructions . . . . . . . . . . ▶

B 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 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))

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 (f) . . 3

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

5 Tax on political expenditures—Schedule F, Part I, column (f) . . . . . . . . . . . 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 statement . 11

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

13 Tax on excess executive compensation—Schedule N . . . . . . . . . . . . . 13

14 Tax on net investment income of private colleges and universities—Schedule O . . . . 14

15 Total (add lines 1–14) . . . . . . . . . . . . . . . . . . . . . . . . 15

Part II 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 Tax on self-dealing—Schedule A, Part II, column (d); and Part III, column (d) . . . . . . 1

2 Tax on investments that jeopardize charitable purposes—Schedule D, Part II, column (d) . 2

3 Tax on taxable expenditures—Schedule E, Part II, column (d) . . . . . . . . . . . 3

4 Tax on political expenditures—Schedule F, Part II, column (d) . . . . . . . . . . 4

5 Tax on disqualifying lobbying expenditures—Schedule H, Part II, column (d) . . . . . . 5

6 Tax on excess benefit transactions—Schedule I, Part II, column (d); and Part III, column (d) . 6

7 Tax on being a party to prohibited tax shelter transactions—Schedule J, Part II, column (d) . 7

8 Tax on taxable distributions—Schedule K, Part II, column (d) . . . . . . . . . . . 8

9 Tax on prohibited benefits—Schedule L, Part II, column (d); and Part III, column (d) . . . 9

10 Total—Add lines 1 through 9 . . . . . . . . . . . . . . . . . . . . . 10

Part III Tax Payments

1 Total tax (Part I, line 15 or Part II, line 10) . . . . . . . . . . . . . . . . . 1

2 Total payments including amount paid with Form 8868 (see instructions) . . . . . . . 2

3 Tax due. If line 1 is larger than line 2, enter amount owed (see instructions) . . . . . . 3

4 Overpayment. If line 1 is smaller than line 2, enter the difference. This is your refund . . . 4

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 13021D Form 4720 (2021)
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SCHEDULE A—Initial Taxes on Self-Dealing (Section 4941)

Part I Acts of Self-Dealing and Tax Computation

(a) Act (c) Correction made?

number (b) Date of act

Yes No (d) Description of act

1

2

3

4

5

(e) Question number from 

Form 990-PF, Part VI-B, 

or Form 5227, Part VIII,

applicable to the act

(f) Amount involved in act (g) Initial tax on self-dealer 

(10% of col. (f))

(h) Tax on foundation managers 

(if applicable) 

(lesser of $20,000 or 5% of col. (f))

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. (g), 

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. (h), 

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 2020 (from Form 990-PF for 2021, Part XII, line 6d) . 1

2 Undistributed income for 2020 (from Form 990-PF for 2021, Part XII, line 6e) . . . . . 2

3 Total undistributed income at end of current tax year beginning in 2021 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

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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 statement) . . . . 4

5 Taxable excess holdings in business enterpriseline 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

Yes No

8 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.

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

Part I Investments and Tax Computation

(c) Correction 

made?

(a) 

Investment

number

(b) Date of 

investment

Yes No

(d) Description of investment (e) Amount of

investment

(f) Initial tax 

on foundation 

(10% of col. (e))

(g) Initial tax on 

foundation managers 

(if applicable)— 

(lesser of $10,000 

or 10% of col. (e))

1

2

3

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 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)

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

Part I Expenditures and Computation of Tax

(a) Item (d) Correction made?

number (b) Amount (c) Date paid or incurred Yes No (e) Name and address of recipient

1

2

3

4

5

(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

(h) Initial tax imposed 

on foundation

(20% of col. (b))

(i) Initial tax imposed on 

foundation managers 

(if applicable)— 

(lesser of $10,000 

or 5% of col. (b))

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 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. (i), 

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

(d) Correction 

made? (a) Item

number (b) Amount (c) Date paidor incurred

Yes No

(e) Description of political expenditure

(f) Initial tax imposed 

on organization 

or foundation

(10% of col. (b))

(g) Initial tax imposed 

on managers 

(if applicable) 

(lesser of $5,000 

or 21⁄2% of col. (b))

1

2

3

4

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 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)

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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

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 . . . . . . . . . . . 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 paidor 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) (c) Correction made?

Transaction

number

(b) Date of transaction

Yes No

(d) Description of transaction

1

2

3

4

5

(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))

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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. (f),

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. (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)

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?

Yes 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 donors, donor advisors, or related persons 

(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 advisors, 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’s, donor advisor’s, or 

related person’s total tax liability 

(add amounts in col. (c)) 

(see instructions)

Part III 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)

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Schedule M—Tax on Hospital Organization for Failure to Meet the Community Health Needs 

Assessment Requirements (Sections 4959 and 501(r)(3)). (See instructions.)

Part I Failures to Meet Section 501(r)(3)

(a) Item 

number (b) Name of hospital 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

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

(a) Item 

number (b) Name of covered employee (c) Excess remuneration (d) Excess parachute 

payment

(e) Total. 

Add column (c) and (d)

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 . . . . . . . . . . . . . . .

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

(a) Name (b) EIN

(c) Gross 

investment income 

(See instructions.)

(d) Capital gain 

net income

(e) Administrative 

expenses allocable 

to income included 

in cols. (c) and (d)

(f) Net investment 

income 

(See instructions.)

1 Filing 

Organization

2 Related 

Organization

3 Related 

Organization

4 Related 

Organization

5 Total from attachment, if necessary . . . . . . 

6 Total . . . . . . . . . . . . . . . .

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

Form 4720 (2021)
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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

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 EIN ▶

Firm’s address ▶ Phone no. 

Form 4720 (2021)