rom 6069 Return of Excise Tax on Excess Contributions to OMB No, 1545-0049

(Rev. April 1991)

Black Lung Benefit Trust Under Section 4953 and

Expires: 2-28-94

q " i NOT Open for
Department ofthe Treasury Computation of Section 192 Deduction Public Inspection
internal Revenue Service
For calendar year 19 , or fiscal year beginning ,19 , and ending ,19
Operator's name Employer identification number
Address (number, street, room, or P. O . box number)
Ifaddress changed, checkhere . . . . . im

City or town, state and ZIP code

Name of related section 501(c)(21) trust

Employer identification number of related trust

RrrMce.y 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 10taxyears . . . . Lab
¢ Any other funding period prescribe or approved by the Secretary of of
the Treasury . . oo . . Lle ]
4 Enterthesmalleroflinelaorlb. .. ......... . Lad Mh
e Enter the largeroflinelcorld . . . . . Je
2a Enter the amount necessary to carry out section soxerean
purposes for the tax year 2a ])
b Enter the fair market value of the trust’ S 5 assets (ee ‘instructions) 2b Uh
¢ Subtract line 2b from line 2a (if less than zero enter zero) . 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 toa

Section 501(c)(21) Trust

la 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). . Le 1b
Excess of line 1a over line 1b (if less than zero enter zero) . le
2 Excess contributions carried over from the preceding tax year 2 Mh
Total (add lines le 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 zero) . So 4
5 Amount of previous year's excess contributions that were returned to
the contributor during the current tax year. Lee 5 UT Mh
6 Total (add lines 4 and 5) . -. [6
7 Excess contributions for current year (subtract line 6 from ‘ine 3Xif less than: zero ro enter zero) 2. . LZ
8 Tax due (enter 5% of line 7). Pay in full with return. (Make check or money order T payable to “Internal
Revenue Service.”) se ... P| 8

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

Please 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 U Title
7 Preparer's Date
paid | Sense b
Preparer's 5
Firm's name (or yours
Use Only | ifself-employed) and
address ZIP code >
For Paperwork Reduction Act Notice, see instructions on the back of the return. Cat. No. 12145 Form 6069 (Rev 4-91)


Form 6069 (Rev. 4-91)

Page 2

General Instructions

(Section references are to the Internal
Revenue Code unless otherwise noted.)
Paperwork Reduction Act Notice.—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 this
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.

The time needed to complete and file this
form will vary depending on individual
circumstances. The estimated average time is:

Recordkeeping. 6hrs., 42 min.
Learning about the

law or the form. 2 hrs., 33 min.
Preparing the form Shrs., 42 min.
Copying, assembling, and

sending the form to 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,
Washington, DC 20224, Attention: IRS.
Reports Clearance Officer, T:FP; 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 the
instructions below on where to file.

Purpose. —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.

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 when only
Schedule A is completed.

When and Where To File.—If you are
required to file Form 6069, you must file it
by the 15th day of the 5th month after the
end of your tax year. File it with the Internal
Revenue Service Center, Cincinnati, OH
45999.

You may file Form 2758, Application for
Extension of Time to File Certain Excise
Income, Information and Other Returns, to
request an extension of time to file Form
6069.

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)(B)(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.

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 instead of filing it with 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:

@ Alladministrative and other incidental
expenses of operating the trust and
processing claims against you (including
legal, actuarial, and trustee expenses).

e All direct payments by the trust for
claims against you.

e 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.

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
(e.g., 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.

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.

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.