Form 6069

(Rev. December 2021)

Department of the Treasury 

Internal Revenue Service 

Return of Certain Excise Taxes on Mine Operators, Black Lung 

Trusts, and Other Persons Under Sections 4951, 4952, and 4953

OMB No. 1545-0047

NOT Open for 

▶ Go to www.irs.gov/Form6069 for instructions and the latest information. Public Inspection

A For calendar year or other tax year beginning , and ending 

B Filer is:

(1) Section 501(c)(21) Trust

(2) Disqualified person; Trustee; Mine operator (see instructions)

C Name of mine operator, trust, or person subject to tax

Number, street, and room or suite no. (or P.O. box number) 

City or town, state, and ZIP code 

D EIN or SSN 

E

Address change

Amended return

F Name of related section 501(c)(21) Trust (if the trust is not the filer) G EIN of the related trust 

H Books and records are in care of: I Telephone no.

Part I Tax and Payment

1 Initial tax on the trust under section 4952(a)(1) (Part III, line 4b) . . . . . . . . . . . . . 1

2 Tax on mine operator under section 4953 (Part IV, line 8) . . . . . . . . . . . . . . . 2

3a Initial tax on self-dealer under section 4951(a)(1) (Part II, line 3d) . . . . . 3a

b Self-dealer’s ratable share of liability (see instructions) . . . . . . . . 3b %

c Filing self-dealer’s liability. Multiply line 3a by percentage share reported on line 3b . . . . . . 3c

4a Initial tax on trustee under section 4951(a)(2) (Part II, line 3e) . . . . . . 4a

b Filing trustee’s ratable share of liability (see instructions) . . . . . . . 4b %

c Filing trustee’s liability. Multiply line 4a by percentage share reported on line 4b . . . . . . . . 4c

5a Initial tax on the trustee under section 4952(a)(2) (Part III, line 4c) . . . . 5a

b Filing trustee’s ratable share of liability (see instructions) . . . . . . . 5b %

c Filing trustee’s liability. Multiply line 5a by percentage share reported on line 5b . . . . . . . . 5c

6 Total tax. Enter the amount from line 1, or the sum of lines 2, 3c, 4c, and 5c . . . . . . . . . 6

7 Total payments, including amount paid with Form 8868 (see instructions) . . . . . . . . . . 7

8 Tax due. If line 6 is larger than line 7, subtract line 7 from line 6 and enter amount owed . . . . ▶ 8

9 Overpayment. If line 6 is smaller than line 7, subtract line 6 from line 7 and enter the amount 

overpaid. This is your refund . . . . . . . . . . . . . . . . . . . . . . . ▶ 9

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 12145E Form 6069 (Rev. 12-2021) 
Form 6069 (Rev. 12-2021) Page 2 

Part II Initial Taxes on Self-Dealing (Section 4951)

1 Acts of self-dealing

(a) Act

number

(b) Date 

of act

(c) Description of act 

(see instructions)

(1)

(2)

2 Computation of initial tax on self-dealing disqualified person or trustee

(a) Act 

number (b) Self-dealer(s) (c) Amount involved 

(d) Initial tax on self-dealer 

(10% (0.10) of col. (c)) 

(see instructions)

(e) Tax on trustee, if applicable 

(2.5% (0.025) of col. (c)) 

(see instructions)

(1)

(2)

3 Totals . . . . . . . . . . . . . . . . . .

4 Corrective action. Attach a detailed statement to describe corrective action taken or to explain why corrective action has not 

been taken. See instructions. 

(a) Act 

number

(b) Has corrective 

action been taken? (c) FMV of amount recovered

Yes No

(1)

(2)

Part III Initial Taxes on Taxable Expenditures and Tax Computation (Section 4952)

1 Taxable expenditures

(a) Item 

number (b) Name and address of recipient (c) Description of expenditure and purposes for which made

(1)

(2)

2 Taxable expenditures by section 501(c)(21) Trust (section 4952(a))

(a) Item 

number (b) Date paid or incurred (c) Amount (d) Trustees

(1)

(2)

3 Computation of initial tax (sections 4952(a)(1) and (2))

(a) Item 

number

(b) Tax imposed on section 501(c)(21) Trust 

(10% (0.10) of line 2, col. (c)) 

(see instructions) 

(c) Tax imposed on Trustee 

(2.5% (0.025) of line 2, col. (c)) 

(see instructions)

(1)

(2)

4 Totals 

5 Corrective action. Attach a detailed statement to describe corrective action taken or to explain why corrective action has not 

been taken. See instructions. 

(a) Act 

number

(b) Has corrective 

action been taken? (c) FMV of amount recovered

Yes No

(1)

(2)

Part IV Tax on Coal Mine Operators Under Section 4953. Computation of Section 4953 Tax by the Person 

Making Excess Contributions Under Section 192 to a Section 501(c)(21) Trust (see instructions)

1 Enter the amount necessary to fund (with level funding) the remaining unfunded liability for claims filed 

or expected to be filed by, or on behalf of, past or present employees of the operator based on:

a The average remaining working life of miners currently employed . . . . 1a

b 10 tax years . . . . . . . . . . . . . . . . . . . . . . 1b

c Any other funding period prescribed or approved by the Secretary of the

Treasury . . . . . . . . . . . . . . . . . . . . . . . 1c

d Enter the smaller of line 1a or 1b . . . . . . . . . . . . . . . 1d

e Enter the larger of line 1c or 1d . . . . . . . . . . . . . . . . . . . . . . . . 1e

Form 6069 (Rev. 12-2021) 
Form 6069 (Rev. 12-2021) Page 3 

Part IV Tax on Coal Mine Operators Under Section 4953. Computation of Section 4953 Tax by the Person 

Making Excess Contributions Under Section 192 to a Section 501(c)(21) Trust (see instructions) 

(continued)

2a Enter the amount necessary to carry out section 501(c)(21)(A) purposes for the

tax year . . . . . . . . . . . . . . . . . . . . . . . 2a

b Enter the fair market value of the trust’s assets. See instructions . . . . . 2b

c Subtract line 2b from line 2a. If zero or less, enter -0- . . . . . . . . . . . . . . . . 2c

3a Contributions made to section 501(c)(21) Trust for operator’s tax year . . . 3a

b Operator’s maximum allowable deduction under section 192 for tax year. 

Enter the larger of line 1e or line 2c . . . . . . . . . . . . . . 3b

c Subtract line 3b from line 3a. If zero or less, enter -0- . . . . . . . . 3c

d Excess contributions carried over from the preceding tax year . . . . . 3d

e Total. Add lines 3c and 3d . . . . . . . . . . . . . . . . . . . . . . . . . 3e

4 Amount that current year’s contributions are less than the maximum amount 

deductible. Subtract line 3a from line 3b. If zero or less, enter -0- . . . . 4

5 Amount of previous year’s excess contributions that were returned to the

contributor during the current tax year . . . . . . . . . . . . . 5

6 Total. Add lines 4 and 5 . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Excess contributions for current year. Subtract line 6 from line 3e. If zero or less, enter -0- . . . . 7

8 Tax imposed on mine operator. Enter 5% (0.05) of line 7 here and in Part I, line 2 . . . . . . . 8

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 trustee Title Date

▲

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator Date

▲

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator Date

▲

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator Date

▲

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator 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 address ▶

Firm’s EIN ▶

Phone no. 

Form 6069 (Rev. 12-2021)