Form 4720 - Return Of Certain Excise Taxes Under Chapters 41 And 42 Of The Internal Revenue Code - 2012 Page 9

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9
Form 4720 (2012)
Page
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)
(d) Tax year hospital
(e) Tax year hospital
(a) Item
facility last conducted a
(b) Name of facility
(c) Description of the failure
facility last adopted an
number
CHNA
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) .
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.
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.
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.
.
.
.
.
.
1
2
Tax—Enter $50,000 multiplied by line 1 here and on Part I, line 12 .
.
.
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.
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.
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.
.
2
4720
Form
(2012)

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