Form 6069

(Rev. February 2012)

Department of the Treasury 

Internal Revenue Service 

Return of Excise Tax on Excess Contributions to 

Black Lung Benefit Trust Under Section 4953 and 

Computation of Section 192 Deduction

OMB No. 1545-0049

NOT Open for 

Public Inspection

For calendar year , or fiscal year beginning , and ending 

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 

Schedule A Worksheet for Computing the Section 192 Deduction by Coal Mine Operators (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 

2 a 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 

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

to a Section 501(c)(21) Trust (See instructions)

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

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

year (enter amount from Schedule A, line 3) . . . . . . . 1b 

c Subtract line 1b from line 1a (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 

8 Tax due (enter 5% of line 7). Pay in full with return. . . . . . . . . . . . . . . ▶ 8 

Please 

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 person filing return Date ▲

Title 

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer's signature Date Check if 

self-employed

PTIN

Firm’s name ▶ Firm's EIN ▶

Firm's address ▶ Phone no.

For Privacy Act and Paperwork Reduction Act Notice, see the back of the return. Cat. No. 12145E Form 6069 (Rev. 2-2012) 
Form 6069 (Rev. 2-2012) Page 2 

General Instructions 

Section references are to the Internal Revenue 

Code unless otherwise noted. 

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 (see Schedule B). 

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. 

When and Where To File. File Form 6069 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, 201 W. River Center Blvd., 

Covington, KY 41011. 

To request an extension of time to file Form 

6069, file Form 8868, Application for Extension 

of Time To File an Exempt Organization Return. 

Accounting Methods. Use the accounting 

method regularly used in keeping your books 

and records. 

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. 

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. 

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. 

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. 

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. 

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). 

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. 

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. 

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. For 

example, $1.39 becomes $1 and $2.50 

becomes $3. 

If you have to add two or more amounts to 

figure the amount to enter on a line, include 

cents when adding the amounts and round off 

only the total. 

Schedule A 

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. 

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. 

Line 2a. Enter the total amount paid during the 

year for any combination of the following: 

• All administrative and other incidental expenses 

of operating the trust and processing claims 

against you (including legal, actuarial, and 

trustee expenses).

• All direct payments by the trust for claims 

against you. 

• All payments of premiums exclusively for 

insurance to cover your liability for claims filed 

under the Black Lung Acts. 

• All payments of accident and health benefits for 

retired miners and their spouses and 

dependents to the extent allowed by section 

501(c)(21)(C). 

Line 2b. Enter the fair market value of the trust’s 

assets at the beginning of your tax year. 

Schedule B 

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. 

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 (for example, 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). 

Line 2. Enter excess contributions carried over 

from Schedule B, Form 6069 for the previous 

year. 

Line 5. Enter excess contributions carried over 

from the prior tax year that were returned to the 

contributor in the current tax year. 

Line 7. Excess contributions entered on this line 

are carried over to the following tax year and 

treated as a contribution for that tax year. 

Line 8. Make check or money order payable to 

the "United States Treasury" for the full amount 

due. 

Signature 

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. 

If a receiver, trustee in bankruptcy, or assignee 

is in control of the operator’s property or 

business, that person must sign the return. 

Generally, anyone who is paid to prepare the 

return must sign it and fill in the "Paid Preparer 

Use Only" area. The signature of the preparer is 

not required if the return is prepared by your 

regular, full-time employee. 

Privacy Act and Paperwork 

Reduction Act Notice 

We ask for the information on this form to carry 

out the Internal Revenue laws of the United 

States. Section 4953 imposes a tax on excess 

contributions to a Black Lung Benefit Trust. You 

are required to give us the information. Section 

6109 requires you to provide your taxpayer 

identification number (EIN or SSN). 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. Failure to provide this information 

in a timely manner, or providing false 

information, may subject you to penalties. 

Routine uses of this information include giving it 

to the Department of Justice for civil and 

criminal litigation, and to cities, states, and the 

District of Columbia for use in the administration 

of their taxes. We may also disclose this 

information to federal and state agencies to 

enforce federal nontax criminal laws and to 

combat terrorism. 

You are not required to provide the information 

requested on a form that is subject to the 

Paperwork Reduction Act unless the form 

displays a valid OMB control number. Books or 

records relating to a form or its instructions must 

be retained as long as their contents may 

become material in the administration of any 

Internal Revenue law. Generally, tax returns and 

return information are confidential, as required by 

Code section 6103. 

The time needed to complete and file this form 

will vary depending on individual circumstances. 

The estimated average time is: 

Recordkeeping . . . . . 7 hr., 10 min. 

Learning about the 

law or the form . . . . . 1 hr., 17 min. 

Preparing the form . . . . 1 hr., 27 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 simpler, we would be happy 

to hear from you. You can write to the Internal 

Revenue Service, Tax Products Coordinating 

Committee, SE:W:CAR:MP:T:M:S, 1111 

Constitution Ave. NW, IR-6526, Washington, DC 

20224. Do not send the tax form to this office. 

Instead, see When and Where To File above.