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

(Rev. August 2002) NOT Open for

Public Inspection Department of the Treasury

Internal Revenue Service

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

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 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

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

“United States Treasury.”) 

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 Privacy Act and Paperwork Reduction Act Notice, see the back of the return. Cat. No. 12145E Form 6069 (Rev. 8-2002)

Schedule B

Schedule A








Form 6069 (Rev. 8-2002) 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 forth in section

501(c)(21)(A)(i)(IV), include only the portion

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

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.

Privacy Act and 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 1 hr., 40 min.

Preparing the form 2 hr., 46 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 Tax

Forms Committee, Western Area Distribution

Center, Rancho Cordova, CA 95743-0001. Do

not send the tax form to this office. Instead, see

When and Where To File above.

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 year.

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.

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:

To request an extension of time to file Form

6069, file Form 8868, Application for Extension

of Time To File an Exempt Organization Return.

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.

● 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).

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.

A Change to Note

When requesting an extension of time to file

Form 6069, use Form 8868, Application for

Extension of Time to File an Exempt

Organization Return, which replaces the Form

2758, Application for Extension of Time To File

Certain Excise, Income, Information and Other

Returns.