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

(Revised October 1981) Black Lung Benefit Trust Under Section 4953 and NOT Open for
Department of the Treas ‘ : ‘ °
internal Revenve Serco Computation of Section 192 Deduction Public Inspection
For calendar year 19 , or fiscal year beginning 719 , and ending ,19
Operator’s Name Employer identification number
Address (number and street)

| If address changed, check here. . > O

City or town, State and ZIP code

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

Rei icw.@e 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 in behalf of, past or present employees of the operator based on:

(a) The average remaining working life of miners currently employed. . . .|2(@).
(b) 10 tax years... . | 1)
(c) Any other funding period prescribed or " approved by the Secretary ¢ of the
Treasury . . ee 1
(d) Enter the smaller of line © 1a) or 1) iC -)

(e) Enter the larger of line 1(c) or 1(d) :
2 (a) Enter the amount necessary to carry out section 501 (c)(21)(A) purposes

forthe tax year... . a. [2a
(b) Enter the fair market value of the trust for the year r (see instructions) . . . {2(b)
(c) Subtract line 2(b) from line 2(a) (if less than zeroenter zero). ©... ee we ee ees | BO)
3 Maximum allowable deduction, enter the larger of line 1(e) or line 2c). . . . _. bh 13

‘Schedule B Computation of Section 4953 Tax by the Person Making Excess
chee Contributions Under Section 192, to a Section 501(c)(21) Trust

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, line3). . 2. 2... se | Ab)
(c) Excess of line 1(a) over line 1(b), (if less than zero enter zero) . . . Ate)
2

2 Excess contributions from preceding tax year .

3 Total (add lines 1(c) and 2) . foe
4 Amount that current year's contributions are less 5 than the maximum amount
deductible (subtract line 1(a) from line 1(b)) (if less than zero enter zero). . |_4
5 Amount of previous year's excess contributions that were returned to the contributor. . 5
6 Total (add lines 4 and 5). Ce

7 Excess contributions for current year (subtract line 6 from line 3) (if less than zero enter zero) .

8 Tax due (enter 5% of line 7). Pay in full with return. (Make check or money order payable to “Internal Rev-
enue Service.”) . . - ee IB

Pl Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my
lease Knowledge and belie, 18 true, correct, and complete. Declaration of preparer (other than taxpayer) 1s based on all information of which preparer
- ‘any knowledge.

Sign as any 6

Here Pama mer oa aie

: Date

A Preparer's

Paid signature >

Preparer’s

Firm's name (or
Use Only yours, if self-employed)
and address ZIP code >

For Paperwork Reduction Act Notice, see instructions on the back of the return. Form 6069 (Rev. 10-81)


General Instructions

(Section references are to the Internal
Revenue Code, unless otherwise indi-
cated.)

Purpose.—Form 6069 is primarily a
worksheet (Schedule A) used to determine
the maximum allowable income tax deduc-
tion (under section 192 of the Internal
Revenue Code) 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 im-
posed under section 4953 for contribu-
tions that are more than the maximum al-
lowable deduction.

Paperwork Reduction Act Notice.—The
Paperwork Reduction Act of 1980 says we
must tell you why we are collecting this in-
formation, how we will use it, and whether
you have to give it to us. We ask for the in-
formation to carry out the Internal Reve-
nue laws of the United States. We need it
to ensure that you are complying with
these laws and to allow us to figure and col-
lect the right amount of tax. You are re-
quired to give us this information.

Who Must File.—Any person who has in-
curred 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 fig-
ured on Schedule B. Do not file it when
only Schedule A is completed.

When and Where to File.—If you are re-
quired 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 Inter-
nal Revenue Service Center, Cincinnati,
OH 45999.

If you need more time, you may file
Form 2758 to request an extension of time
to file Form 6069.

Accounting Methods.—Use the ac-
counting method regularly used in keep-
ing your books and records.

Accounting Period.—Complete the re-
turn on the basis of your established ac-
counting period. If you do not have an es-
tablished accounting period, use the cal-
endar year,

Penalties and Interest.—There are pen-
alties for late filing, willful failure to file,
and for filing fraudulent returns and state-
ments. See sections 6651, 7203, 7206,
and 7207 of the Code.

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 Coal Mine
Health and Safety 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 dis-
ability or death due to pneumoconiosis
under the Black Lung Acts.

Unless otherwise indicated, the term
“trust’’ used in the instructions means the

tax exempt section 501(c)(21) black lung
benefit trust or trusts which you claim con:
tributions deductions to under section
192,

Specific Instructions

No deduction will be allowed under sec-
tion 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 on account of a partic-
ular tax year that are made no later than
the due date (including extensions) of your
income tax return for that tax year will be
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 ac-
counting period you are reporting.

Name and Address.—Enter your name,
address, and employer identification num-
ber in the appropriate spaces. In the
spaces for the name and employer identifi-
cation 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 should show the money
items on the return and accompanying
schedules as whole-dollar amounts. To do
so, eliminate any amount less than 50
cents and increase any amount from 50
gents through 99 cents to the next higher

jollar.

Schedule A

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 ac-
tuarial assumptions consistent with regu-
lations to be issued by the Secretary of the
Treasury. On lines 1(a), 1(b), and 1(c)
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 1(e).—Enter the largest amount
you expect to need to pay claims against
you using one of the projections on line
1(c) or 1(d).

Line 2(a).—Enter the total amount paid
during the year for any combination of the
following:

© All administrative and other inciden-

tal expenses of operating the trust
and processing claims against you
(including legal, actuarial, and trust-
ee expenses).

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

All payments of premiums exclusive-

ly for insurance to cover your liability

for claims filed under the Black Lung
cts.

‘4 US, GOVERNMENT PRINTING OFFICE : 1981—O~343-383

Line 2(b).—Enter the fair market value
of the trust's assets at the beginning of
your tax year.

Line 3.—Enter the amount from line
1(e) or 2(c), whichever is larger.

If you are completing Schedule A only
to figure the maximum allowable deduc-
tion and do not owe tax on excess contribu-
tions, keep this form instead of filing it
with IRS.

Schedule B

Complete Schedule B only for tax years
in which your contributions to black lung
benefit trusts are more than the maximum
allowable deduction under section 192.

Line 1(a).—Enter the amount contrib-
uted to section 501(c)(21) trusts for the
year.

Line 1(b).—Enter the amount from line
3, Schedule A of Form 6069.

Line 1(c).—Subtract line 1(b) from
1(a).

Line 2.—If you made contributions for a
tax year under section 192(a) that totaled
more than the maximum allowable de-
duction under section 192(b) for that tax
year, the excess is carried over to the next
tax year and treated as a contribution to
the trust in that tax year. Enter any excess
contributions from the previous year's
Schedule B, Form 6069.

Line 4.—Enter the amount by which
line 1(b) is more than 1(a) or zero.

Line 5.—If you made excess contribu-
tions to a black lung benefit trust for a tax
year, the trust will, at your request, repay
the amount of the excess contributions,
but not more than the excess. The payment
will not be an act of self-dealing or a tax-
able expenditure, but the repayment does
not remove your liability for the tax on
excess contributions. Enter any excess
contributions from the previous year's
Form 6069 that the trust returned to you.

Line 8.—Enter 5% of the amount on
line 7.

Signature

If you are filing for a corporation, the
return must be signed by the president,
vice president, treasurer, assistant treas-
urer, 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 who 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.