4720
Return of Certain Excise Taxes Under Chapters
OMB No. 1545-0052
Form
41 and 42 of the Internal Revenue Code
2014
(Sections 170(f)(10), 664(c)(2), 4911, 4912, 4941, 4942, 4943, 4944, 4945, 4955, 4958, 4959, 4965, 4966, and 4967)
Department of the Treasury
Information about Form 4720 and its separate instructions is at
Internal Revenue Service
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For calendar year 2014 or other tax year beginning
, 2014, and ending
, 20
Employer identification number
Name of organization or entity
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 or province, country, and ZIP or foreign postal code
Form 990-PF
Form 5227
Yes No
A
Is the organization a foreign private foundation within the meaning of section 4948(b)?
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Has corrective action been taken on any taxable event that resulted in Chapter 42 taxes being reported on this
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form? (Enter “N/A” if not applicable) .
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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
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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))
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Tax on undistributed income—Schedule B, line 4 .
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Tax on excess business holdings—Schedule C, line 7 .
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3
Tax on investments that jeopardize charitable purpose—Schedule D, Part I, column (e) .
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4
Tax on taxable expenditures—Schedule E, Part I, column (g) .
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Tax on political expenditures—Schedule F, Part I, column (e) .
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Tax on excess lobbying expenditures—Schedule G, line 4 .
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Tax on disqualifying lobbying expenditures—Schedule H, Part I, column (e) .
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Tax on premiums paid on personal benefit contracts
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Tax on being a party to prohibited tax shelter transactions—Schedule J, Part I, column (h) .
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Tax on taxable distributions—Schedule K, Part I, column (f)
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Tax on a charitable remainder trust’s unrelated business taxable income. Attach statement .
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Tax on failure to meet the requirements of section 501(r)(3)-Schedule M, Part II, line 2
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Total (add lines 1–12) .
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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. City or town, state or province, country, ZIP or foreign postal code
(b) Taxpayer identification number
a
b
c
(d) Tax on investments that jeopardize
(c) Tax on self-dealing—Schedule A, Part II,
(e) Tax on taxable expenditures—
(f) Tax on political expenditures—
charitable purpose—Schedule D,
col. (d), and Part III, col. (d)
Schedule E, Part II, col. (d)
Schedule F, Part II, col. (d)
Part II, col. (d)
a
b
c
Total
(h) Tax on excess benefit
(i) Tax on being a party to prohibited
(g) Tax on disqualifying lobbying
(j) Tax on taxable distributions—
transactions—Schedule I, Part II, col.
tax shelter transactions—Schedule J,
expenditures—Schedule H, Part II, col. (d)
Schedule K, Part II, col. (d)
(d), and Part III, col. (d)
Part II, col. (d)
a
b
c
Total
(k) Tax on prohibited benefits—Sch L,
(l) Total—Add cols. (c) through (k)
Part II, col. (d), and Part III, col. (d)
a
b
c
Total
4720
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Form
(2014)
Cat. No. 13021D