Return of Excise Tax on Excess Contributions to OMB No. 1545-0049

Black Lung Benefit Trust Under Section 4953 and

Computation of Section 192 Deduction

Form 6069 Expires: 1-31-97

(Rev. January 1994) NOT Open for

Public Inspection Department of the Treasury

Internal Revenue Service

For calendar year 19 , or fiscal year beginning , 19 , and ending , 19

Operator’s name Employer identification number

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

If address changed, check here ©

City or town, state and ZIP code

Name of related section 501(c)(21) trust Employer identification number of related trust

Worksheet for Computing the Section 192 Deduction by Coal Mine Operators

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

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 less than zero enter -0-) 2c

3 Maximum allowable deduction (enter the larger of line 1e or line 2c) © 3

Computation of Section 4953 Tax by the Person Making Excess Contributions Under Section 192

to a Section 501(c)(21) Trust

1a Contributions made to section 501(c)(21) trust for operator’s tax year 1a

Operator’s maximum allowable deduction under section 192 for

tax year (enter amount from Schedule A, line 3)

b

1b

c Excess of line 1a over line 1b (if less than zero, enter -0-) 1c

2 Excess contributions carried over from the preceding tax year 2

3 Total (add lines 1c and 2) 3

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

maximum amount deductible (subtract line 1a from line 1b) (if less

than zero, 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 3)(if less than zero, enter -0-) 7

Tax due (enter 5% of line 7). Pay in full with return. (Make check or money order payable to

“Internal Revenue Service.”) ©

8

8

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

Please 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

Here

Signature of person filing return Date Title

Date Preparer’s Paid signature

Preparer’s

Use Only Firm’s name (or yours

if self-employed) and

address ZIP code ©

For Paperwork Reduction Act Notice, see instructions on the back of the return. Cat. No. 12145E Form 6069 (Rev 1-94)

Schedule B

Schedule A

©

©

©

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Form 6069 (Rev. 1-94) Page 2

● All administrative and other incidental

expenses of operating the trust and

processing claims against you (including

legal, actuarial, and trustee expenses). For

expenses attributable to the purposes set

Interest at the annual rate provided by law

is charged on any tax shown on line 8,

Schedule B, that is not paid by the due date

of the return.

General Instructions

Section references are to the Internal

Revenue Code unless otherwise noted.

Paperwork Reduction Act

Notice ● All direct payments by the trust for claims

against you.

Definitions

The term “Black Lung Acts” refers to Part C

of Title IV of the Federal Mine Safety and

Health Act of 1977, and any state law that

provides compensation for disability or death

due to pneumoconiosis (black lung disease).

A black lung benefit claim is a claim for

compensation for disability or death due to

pneumoconiosis under the Black Lung Acts.

● All payments of premiums exclusively for

insurance to cover your liability for claims

filed under the Black Lung Acts.

Line 2b.—Enter the fair market value of the

trust’s assets at the beginning of your tax

year.

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated average time

is:

Schedule B

Recordkeeping 6 hr., 42 min.

Complete Schedule B only if your

contributions to black lung benefit trusts for

the current tax year are more than the

maximum allowable deduction under section

192 or if you made excess contributions in

the preceding tax year that are carried over to

the current tax year. The contributor must pay

a tax in the current tax year on excess

contributions carried over from the preceding

tax year unless the trust returns the excess

contributions to the contributor or the

contributor offsets excess contributions by

reduced contributions in the current tax year.

Unless otherwise indicated, the term “trust”

as used in the instructions means the

tax-exempt section 501(c)(21) trust or trusts

to which you made contributions for which

you claimed a deduction under section 192.

Learning about the

law or the form 2 hr., 33 min.

Preparing the form 3 hr., 42 min.

Copying, assembling, and

sending the form to the IRS 16 min.

If you have comments concerning the

accuracy of these time estimates or

suggestions for making this form more

simple, we would be happy to hear from you.

You can write to both the Internal Revenue

Service, Attention: Reports Clearance Officer,

PC:FP, Washington, DC 20224; and the

Office of Management and Budget,

Paperwork Reduction Project (1545-0049),

Washington, DC 20503. DO NOT send the

tax form to either of these offices. Instead,

see When and Where To File below.

Specific Instructions

No deduction is allowed under section 192(a)

for any contribution to a trust other than a

contribution in cash or in items in which the

trust may invest under section

501(c)(21)(A)(ii)(II).

Line 1a.—When an excess contribution is

made to a section 501(c)(21) trust in the

current tax year and the trust returns part or

all of the current year’s excess contribution in

the same year, show only the net contribution

for the year on this line (i.e., current year’s

contribution less current year’s excess

contribution returned). At your request, a

black lung benefit trust will repay excess

contributions (but not more than the excess)

made to the trust for a tax year. The

repayment is not an act of self-dealing or a

taxable expenditure reportable on Schedule A

(Form 990-BL).

Payments made for a particular tax year

that are made no later than the due date

(including extensions) of your income tax

return for that tax year are considered to

have been made on the last day of that tax

year.

Purpose of Form.—Form 6069 is primarily a

worksheet (Schedule A) used to determine

the maximum allowable income tax deduction

(under section 192) for contributions made by

coal mine operators to tax-exempt black lung

benefit trusts. The form is also used to

determine the amount of excise tax imposed

under section 4953 for contributions that are

more than the maximum allowable deduction.

Period To Be Covered by Return.—Fill in

the spaces at the top of the form to show the

calendar year or fiscal year of the accounting

period you are reporting.

Name and Address.—Enter your name,

address, and employer identification number

in the appropriate spaces. In the spaces for

the name and employer identification number

of the related trust, enter the identifying

information for the black lung benefit trust to

which you made excess contributions.

Line 2.—Enter excess contributions carried

over from Schedule B, Form 6069 for the

previous year.

Who Must File.—Any person who has

incurred liability for the excise tax on excess

contributions under section 4953 must file a

return on Form 6069. File Form 6069 only to

report the excise tax liability figured on

Schedule B. Do not file it if only Schedule A

is completed.

Line 5.—Enter excess contributions carried

over from the prior tax year that were

returned to the contributor in the current tax

year.

Rounding Off to Whole-Dollar Amounts.—

You may show the money items on the return

and accompanying schedules as whole-dollar

amounts. To do so, drop any amount less

than 50 cents and increase any amount from

50 cents through 99 cents to the next higher

dollar.

Line 7.—Excess contributions entered on this

line are carried over to the following tax year

and treated as a contribution for that tax

When and Where To File.—File Form 6069 year.

by the 15th day of the 5th month after the

end of your tax year. If the regular due date

falls on a Saturday, Sunday, or legal holiday,

file on the next business day. File it with the

Internal Revenue Service Center, Cincinnati,

OH 45999.

Schedule A

Signature

If you are completing Schedule A only to

figure the maximum allowable deduction and

do not owe tax on excess contributions, keep

this form with your records instead of filing it

with the IRS. If you are filing for a corporation, the return

must be signed by the president, vice

president, treasurer, assistant treasurer, chief

accounting officer or any other officer (such

as tax officer) authorized to sign. If you are

filing for a partnership, one general partner

must sign. If you are filing for a sole

proprietorship, the owner must sign.

Line 1.—The determination of amounts

necessary to cover payments for claims made

under the Black Lung Benefits Acts of 1977

must be based on reasonable actuarial

assumptions. On lines 1a, 1b, and 1c, enter

the annual amounts you need to fund (with

level funding) all claims against you that were

filed or expected to be filed by, or on behalf

of, past or present employees for

compensation because of disability or death,

due to pneumoconiosis, under the Black

Lung Acts.

Accounting Methods.—Use the accounting

method regularly used in keeping your books

and records.

If a receiver, trustee in bankruptcy, or

assignee is in control of the operator’s

property or business, that person must sign

the return.

Accounting Period.—Complete the return on

the basis of your established accounting

period. If you do not have an established

accounting period, use the calendar year.

The return must also be signed by any

person, firm, or corporation that prepared the

return. If the return is prepared by a firm or

corporation, it should be signed in the name

of the firm or corporation. The signature of

the preparer is not required if the return is

prepared by your regular, full-time employee.

Penalties and Interest.—There are penalties

for late filing, willful failure to file, and for filing

fraudulent returns and statements. See

sections 6651, 7203, 7206, and 7207.

Line 2a.—Enter the total amount paid during

the year for any combination of the following:

Printed on recycled paper

To request an extension of time to file Form

6069, file Form 2758, Application for

Extension of Time to File Certain Excise

Income, Information and Other Returns.

We ask for the information on this form to

carry out the Internal Revenue laws of the

United States. You are required to give us the

information. We need it to ensure that you are

complying with these laws and to allow us to

figure and collect the right amount of tax. ● All payments of accident and heatlh

benefits for retired miners and their spouses

and dependents to the extent allowed by

section 501(c)(21)(C).

forth in section 501(c)(21)(A)(i)(IV), include only

the portion allowed by section 501(c)(21)(C).