Return of Certain Excise Taxes Under Chapters                                                                 OMB No. 1545-0047
Form  4720                        41 and 42 of the Internal Revenue Code
                                  (Sections 170(f)(10), 664(c)(2), 4911, 4912, 4941, 4942, 4943, 4944, 
Department of the Treasury                         4945, 4955, 4958, 4959, 4960, 4965, 4966, 4967, and 4968)                              2021 
Internal Revenue Service        ▶ Go to www.irs.gov/Form4720 for instructions and the latest information.
For calendar year 2021 or other tax year beginning                                               , 2021, and ending                               , 20
Name of organization, entity, or person subject to tax                                                                     EIN or SSN

Number, street, and room or suite no. (or P.O. box if mail is not delivered to street address)                               Amended return
                                                                                                                           Check box for type of annual return:
City or town, state or province, country, and ZIP or foreign postal code                                                     Form 990        Form 990-EZ
                                                                                                                             Form 990-PF     Other
                                                                                                                             Form 5227
                                                                                                                                                 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)

Form 4720 (2021)                                                                                                                                                    Page 2
                                     SCHEDULE A—Initial Taxes on Self-Dealing (Section 4941)
Part I       Acts of Self-Dealing and Tax Computation
(a) Act      (b) Date of act     (c) Correction made?                                                     (d) Description of act
number                              Yes         No
1
2
3
4
5
    (e) Question number from                                                                                                        (h) Tax on foundation managers 
        Form 990-PF, Part VI-B,                 (f) Amount involved in act                    (g) Initial tax on self-dealer                   (if applicable) 
        or Form 5227, Part VIII,                                                                  (10% of col. (f))                 (lesser of $20,000 or 5% of col. (f))
        applicable to the act

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         (c) Tax from Part I, col. (g),      (d) Self-dealer’s total tax liability 
                                                                             Part I, col. (a)               or prorated amount              (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         (c) Tax from Part I, col. (h),      (d) Manager’s total tax liability 
                                                                             Part I, col. (a)               or prorated amount              (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
                                                                                                                                                       Form 4720 (2021)

Form 4720 (2021)                                                                                                                                                  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)                                                            (c)  
                                                                                    Voting stock                         (b)                      Nonvoting stock  
                                                                                (profits interest or                  Value                       (capital interest)
                                                                                beneficial 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  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
                                                                                                                                                            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
                                                                                                                                                    (g) Initial tax on 
(a)        (b) Date of     (c) Correction                  (d) Description of investment              (e) Amount of             (f) Initial tax   foundation managers 
Investment investment              made?                                                              investment              on foundation         (if applicable)—  
number                                                                                                                        (10% of col. (e))     (lesser of $10,000 
                        Yes            No                                                                                                           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
                                                                   (b) Investment 
           (a) Names of foundation managers liable for tax         no. from Part I,           (c) Tax from Part I, col. (g),          (d) Manager’s total tax liability 
                                                                           col. (a)               or prorated amount                        (add amounts in col. (c)) 
                                                                                                                                                (see instructions)

                                                                                                                                                    Form 4720 (2021)

Form 4720 (2021)                                                                                                                                           Page 4
                            SCHEDULE E—Initial Taxes on Taxable Expenditures (Section 4945)
Part I   Expenditures and Computation of Tax
(a) Item (b) Amount           (c) Date paid          (d) Correction made?                            (e) Name and address of recipient
number                        or incurred                Yes        No
1
2
3
4
5
                                                                                   (g) Question number from                                 (i) Initial tax imposed on 
                                                                                   Form 990-PF, Part VI-B,  (h) Initial tax imposed         foundation managers 
         (f) Description of expenditure and purposes for which made                or Form 5227, Part VIII,       on foundation                 (if applicable)— 
                                                                                       applicable to the         (20% of col. (b))              (lesser of $10,000 
                                                                                        expenditure                                             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      (c) Tax from Part I, col. (i),         (d) Manager’s total tax liability 
                                                                      Part I, col. (a)         or prorated amount                  (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                                                  (f) Initial tax imposed    (g) Initial tax imposed 
(a) Item (b) Amount           (c) Date paid              made?          (e) Description of political expenditure          on organization           on managers 
number                        or incurred                                                                                 or foundation             (if applicable) 
                                                     Yes       No                                                         (10% of col. (b))     (lesser of $5,000 
                                                                                                                                                or 2½% 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                  (b) Item no. from      (c) Tax from Part I, col. (g),         (d) Manager’s total tax liability 
                 foundation managers liable for tax                   Part I, col. (a)         or prorated amount                  (add amounts in col. (c)) 
                                                                                                                                        (see instructions)

                                                                                                                                                Form 4720 (2021)

Form 4720 (2021)                                                                                                                                             Page 5
                          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
                                                                                                                   (e) Tax imposed           (f) Tax imposed on 
(a) Item       (b) Amount           (c) Date paid            (d) Description of lobbying expenditures              on organization           organization managers 
number                                 or incurred                                                                 (5% of col. (b))               (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         (c) Tax from Part I, col. (f),       (d) Manager’s total tax liability 
                                                                     Part I, col. (a)                or prorated amount             (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  (b) Date of transaction                                                         (d) Description of transaction
number                                 Yes         No
    1
    2
    3
    4
    5
           (e) Amount of excess benefit                      (f) Initial tax on disqualified persons                   (g) Tax on organization managers 
                                                                     (25% of col. (e))                                            (if applicable) 
                                                                                                                       (lesser of $20,000 or 10% of col. (e))

                                                                                                                                                  Form 4720 (2021)

Form 4720 (2021)                                                                                                                                             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
                                                                          (b) Trans. no.                                             (d) Disqualified person’s 
            (a) Names of disqualified persons liable for tax              from Part I,            (c) Tax from Part I, col. (f),         total tax liability 
                                                                                 col. (a)             or prorated amount             (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         (b) Trans. no.          (c) Tax from Part I, col. (g),     (d) Manager’s total tax liability 
                       managers liable for tax                            from Part I,                or prorated amount             (add amounts in col. (c)) 
                                                                                 col. (a)                                                (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)
                                           (c) Type of transaction 
    (a)                                1 —Listed 
Transaction     (b) Transaction date   2 —Subsequently listed                                          (d) Description of transaction
number                                 3 —Confidential 
                                       4 —Contractual protection
    1

    2

    3

    4

    5

(e) Did the tax-exempt entity know or have                                                                                               Tax imposed on 
reason to know this transaction was a PTST           (f) Net income attributable            (g) 75% of proceeds attributable         (h) 
when it became a party to the transaction?                   to the PTST                            to the PTST                      the tax-exempt entity 
                                                                                                                                         (see instructions)
        Yes                     No

Total—Column (h). Enter here and on Part I, line 9 .                . . . .      . .      . .   .   .  .   .   .  .    .    .
                                                                                                                                               Form 4720 (2021)

Form 4720 (2021)                                                                                                                                           Page 7
Part II      Tax Imposed on Entity Managers (Section 4965) Continued
                                                                  (b) Transaction            (c) Tax—enter $20,000 for 
                 (a) Name of entity manager                         number from          each transaction listed in col. (b) (d) Manager’s total tax liability 
                                                                    Part I, col. (a)     for each manager in col. (a)                (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              (b) Name of sponsoring organization and                                             (c) Description of distribution
number                        donor advised fund

1

2

3

4

    (d) Date of distribution           (e) Amount of distribution                    (f) Tax imposed on organization         (g) Tax on fund managers 
                                                                                             (20% of col. (e))               (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
                                                                    (b) Item no. 
             (a) Name of fund managers liable for tax               from Part I,             (c) Tax from Part I, col. (g)   (d) Manager’s total tax liability 
                                                                      col. (a)                   or prorated amount                  (add amounts in col. (c))  
                                                                                                                                         (see instructions)

                                                                                                                                              Form 4720 (2021)

Form 4720 (2021)                                                                                                                                      Page 8
         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         (b) Date of                                                  (c) Description of benefit
number           prohibited benefit

1

2

3

4

5
                                                       (e) Tax on donors, donor advisors, or related persons (f) Tax on fund managers (if applicable) 
         (d) Amount of prohibited benefit                  (125% of col. (d))                                (lesser of 10% of col. (d) or $10,000) 
                                                           (see instructions)                                           (see instructions)

Part II  Summary of Tax Liability of Donors, Donor Advisors, Related Persons, and Proration of Payments
                                                                                                                        (d) Donor’s, donor advisor’s, or 
             (a) Names of donors, donor advisors, or       (b) Item no.           (c) Tax from Part I, col. (e)         related person’s total tax liability 
                 related persons liable for tax            from Part I,           or prorated amount                        (add amounts in col. (c)) 
                                                           col. (a)                                                              (see instructions)

Part III Summary of Tax Liability of Fund Managers and Proration of Payments
                                                           (b) Item no. 
             (a) Names of fund managers liable for tax     from Part I,           (c) Tax from Part I, col. (f)         (d) Fund manager’s total tax liability 
                                                           col. (a)               or prorated amount                        (add amounts in col. (c)) 
                                                                                                                                 (see instructions)

                                                                                                                                          Form 4720 (2021)

Form 4720 (2021)                                                                                                                                    Page 9
         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)
                                                                                                                 (d) Tax year hospital   (e) Tax year hospital 
(a) Item         (b) Name of hospital facility                 (c) Description of the failure                    facility last conducted facility last adopted an 
number                                                                                                              a 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)  .      . .   .            . .   . .  .   .   .  .   .    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              (b) Name of covered employee                (c) Excess remuneration             (d) Excess parachute               (e) Total. 
number                                                                                                   payment               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)
                                                                       (c) Gross                                    (e) Administrative 
                               (a) Name                (b) EIN       investment income          (d) Capital gain    expenses allocable   (f) Net investment 
                                                                     (See instructions.)          net income        to income included       income 
                                                                                                                    in cols. (c) and (d) (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)

Form 4720 (2021)                                                                                                                                               Page 10
                  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.

                 ▲
Sign              Signature of officer or trustee                                                             Title                                        Date
Here

                 ▲
                  Signature (and organization or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor                     Date
                  advisor, or related person
                 May the IRS discuss this return with the preparer shown below? (see instructions)  . . . . . . .   . .                 . . .              Yes No
                 Print/Type preparer’s name       Preparer’s signature                                      Date
Paid                                                                                                                                    Check          if  PTIN
                                                                                                                                        self-employed 
Preparer                         ▶                                                                                                      Firm’s EIN ▶
                 Firm’s name     
Use Only         Firm’s address ▶                                                                                                       Phone no. 
                                                                                                                                                    Form 4720 (2021)