Form 5227 (2019)
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Part VI-B Statements Regarding Activities for Which Form 4720 May Be Required
File Form 4720 if any item is checked in the “Yes” column (to the right), unless an exception applies. Yes No
75 Self-dealing (section 4941):
a During 2019, did the trust (either directly or indirectly):
(1) Engage in the sale or exchange, or leasing of property with a disqualified person?
Yes No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person? . . . . . . . . . . . . . . . . . . . . .
Yes No
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? .
Yes No
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? .
Yes No
(5) Transfer any income or assets to a disqualified person (or make any of either available
for the benefit or use of a disqualified person)? . . . . . . . . . . . . .
Yes No
(6)
Agree to pay money or property to a government official? (Exception. Check “No” if
the trust agreed to make a grant to or to employ the official for a period after
termination of government service, if terminating within 90 days.) . . . . . . .
Yes No
b
If any answer is “Yes” to lines 75a(1) through (6), did any of the acts fail to qualify under the exceptions
described in Regulations sections 53.4941(d)-3 and 4, or in a current Notice regarding disaster assistance
(see the instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75b
Organizations relying on a current Notice regarding disaster assistance, check here . . . .
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c
Did the trust engage in a prior year in any of the acts described in line 75a, other than excepted acts, that
were not corrected before January 1, 2019? . . . . . . . . . . . . . . . . . . . . .
75c
76 Does section 4947(b)(3)(A) or (B) apply? (see the instructions) . . . . . . . . . . Yes No
If “Yes,” check the “N/A” box in lines 77 and 78.
77 Taxes on excess business holdings (section 4943):
N/A
a Did the trust hold more than a 2% direct or indirect interest in any business enterprise at
any time during 2019? . . . . . . . . . . . . . . . . . . . . . .
Yes No
b
If “Yes,” did the trust have excess business holdings in 2019 as a result of (1) any purchase by the trust or
disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved by the
Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or
(3) the lapse of the 10-, 15-, or 20-year first phase holding period? . . . . . . . . . . . . . .
77b
Use Schedule C, Form 4720, to determine if the trust had excess business holdings in 2019.
78 Taxes on investments that jeopardize charitable purposes (section 4944): N/A
a Did the trust invest during 2019 any amount in a manner that would jeopardize its charitable purpose? . .
78a
b Did the trust make any investment in a prior year (but after December 31, 1969) that could jeopardize its
charitable purpose that had not been removed from jeopardy before January 1, 2019? . . . . . . .
78b
79 Taxes on taxable expenditures (section 4945) and political expenditures (section 4955):
a During 2019, did the trust pay or incur any amount to:
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
Yes No
(2) Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive? . . . . . . . . . . .
Yes No
(3) Provide a grant to an individual for travel, study, or other similar purposes? . . . .
Yes No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 509(a)(1), (2), or (3), or section 4940(d)(2)? . . . . . . . . . . . .
Yes No
(5) Provide for any purpose other than religious, charitable, scientific, literary, or
educational, or for the prevention of cruelty to children or animals? . . . . . .
Yes No
b
If any answer is “Yes” to lines 79a(1) through (5), did any of the transactions fail to qualify under the
exceptions described in Regulations section 53.4945, or in a current Notice regarding disaster assistance
(see the instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79b
Organizations relying on a current Notice regarding disaster assistance, check here . . . .
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c If the answer is “Yes” to line 79a(4), does the trust claim exemption from the tax because
it maintained expenditure responsibility for the grant? . . . . . . . . . . . . Yes No
If “Yes,” attach the statement required by Regulations section 53.4945-5(d).
80 Personal benefit contracts (section 170(f)(10)):
a Did the trust, during the year, receive any funds, directly or indirectly, to pay premiums on
a personal benefit contract? . . . . . . . . . . . . . . . . . . . .
Yes No
b Did the trust, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . . .
80b
If “Yes” to line 80b, file Form 8870 (see the instructions).
Form 5227 (2019)