rom 990-BL Information and Initial Excise Tax Return for Black
(Rev. August 1988) Lung Benefit Trusts and Certain Related Persons = | ovens 155000

Department of the Treasury (Under section 501(c)(21) of the Internal Revenue Code)

For calendar year 19 _ or fiscal year beginning 119 and ending 19
Name of trust Employer identification number (see instructions).

Social security number (see instructions)

Name of other person filing return (see instructions)

Address of filer (number and street) If application pending, checkhere. . >
Ifaddress changed, checkhere. . >
City or town, state and ZIP code FMV of assets at beginning

of operator's taxyear . >

Return filed by (see
Trust Mette tan

Analysis of Revenue and Expenses (see instructions)

1 Contributonsreceived «ss «tg

2 Investment income:
a Interest on certain securities of the U.S., state, and local governments . .
b Interest on time or demand deposits in a bank or insured credit union (described i in section
501(c)(21)(B)(ii)(III)) fn
¢ Gross amount received from sale of assets
Minus cost or other basis and sales expenses.
Net gain or (loss)
d Other income (attach schedule) . ee  ?
3 Total revenue (addlines1lthrough2d) . we Ct rrr
4 Contributions to the Federal Black Lung Disability Trust Fund .
5 Premiums for insurance to cover liabilities described in section 501(cX21)(A)(i).
6 Other payments to or for benefit of eligible coal miners or beneficiaries
7 Compensation of trustees .
8 Other salaries and wages
9 Administrative expenses not included on vines 7 and 8 (attach schedule) .

10 Other (attach schedule) ee
11 Total expenses (add lines 4 through 10). oa err SS

12 Excess of revenue over expenses (subtract line 11 from line 3). woe ee L12
Balance Sheets ‘ Beginning of year End of year

13
14

eral Instruction A and Specific Instruction B, check box that applies): _
ii 1 Trustee “*atpectony (_ Disqualified person “*itpuctan)

Revenue

Expenses

13 Cash . coe
14 Savings and interest bearing accounts . rs
15 Investments in approved securities . 15
16 Office supplies and equipment oe ee ee E16
17 Other (attachscheduley . . . Poe ee ee ee LZ
18 Total assets (add lines 13 through 17)_ ee 18
19
20

Assets

19 Liabilities (see instructions)
20 Net worth or capital account .

Liabilities
and
Net Worth

21 Total liabilities and net worth (addlines19and20)_. . . . . h | 21

The books are in care of >
Located at >

Pl Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
ASE | belief, itis true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign y >
Here Signature of person filing return Date Title

. Preparer's Date
Paid | signature
Preparet’s Firms name (or
Use Only | yours, if self-employed)

and address ZIP code

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 990-BL (Rev. 8-88)


Form 990-BL (Rev. 8-88)

Page 2

J Part 11 Questionnaire

Yes} No

22 Have any changes not previously reported to the Internal Revenue Service been made in your governing instrument, or
other instrument of similar import? . .
If “Yes,”’ attach a conformed copy of the changes.
23 Self-dealing (section 4951):
a Have you engaged in any of the following acts during the year either directly or indirectly, with one or more
disqualified persons (see instructions for definition)X—
(1) Sale, exchange, or leasing of property? .
(2) Borrowing or lending of money or other extension of credit? .
(3) Furnishing of goods, services, or facilities?
(4) Payment of compensation (or payment or reimbursement of expenses)?
(5) Transfer to, or use by or for the benefit of, a disqualified person of any part of your income or orassets?

b If any of questions 23a(1) through 23a(5) is answered ‘‘Yes,"’ were all of the acts in which you engaged excepted acts

described in the instructions?

¢ If 23bis ‘'No," complete Schedule A (Form 9904 BL), Part I, ‘Section A.

24 Taxes on taxable expenditures (section 4952):
During the year did you pay, or incur a liability to pay any amount for any purpose other than for payment of: (1) black
lung benefits, (2) administrative expenses of the trust, (3) premiums for insurance covering liabilities for black lung
benefits, (4) permitted investments of trust funds, (5) transfer of funds to the Federal Black Lung Disability Fund or to the
general fund of the U.S. Treasury, or (6) return of excess contributions to the coal mine operator who contributed them?
If “Yes,” complete Schedule A (Form 990-BL), Part I, Section B.

25 Has corrective action been taken with respect to any transaction which resulted in Chapter 42 taxes being reported on

Schedule A (Form 990-BL)? .

If “Yes,” attach a detailed documentation and description of the corrective action ntaken and, ‘it applicable, enter the fair

market value of any property recovered as a result of the correction P $ ___.._.-._-----.
(for any uncorrected acts, attach explanation (see instructions)).

_

26 Officers, directors, trustees and their compensation, if any, for the tax year:

Contributions Expense account,
Title and time j
Name and Address ne to employee other Compensation
devotedtoposition | benefit plans | allowances

Total 2.

Statement With Respect to Contributors, etc. (Not open for public inspection)

1 Persons who contributed $5,000 or more in the taxable year (if more space is needed, attach schedule):

Name Address

2 During the period covered by this return did the trust receive any contributions in excess of the maximum allowable
deduction for the contributor under section 192? ee

Yes| No



Cee poonL) Computation of Initial Excise Taxes on OMB No, 1545-0049

(Rev. August 1988) Black Lung Benefit Trusts and Certain Related Persons | NOT Open pen for

Pepartment of the Treasury (Under sections 4951 and 4952 of the Internal Revenue Code) Public Inspection

For the calendar year 19 _or fiscal year beginning 19 and ending 119

Name of trust/person filing return (see instructions) Employer Identification number or social
instructions) ner ee

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

Return filed by (See instructions, check box that applies):
O Trust 1 Trustee (Disqualified person

Initial Taxes on Self-dealing (Section 4951) and Taxable Expenditures (Section 4952)
SECTION A.—Acts of Self-dealing and Tax Computation (Section 4951)

saraber (b) Date of act (©) Description of act

RADE

(d) Names of disqualified persons liable for tax (e) Names of trustees liable for tax

(f) Amount involved in act (2) Initial tax ot ea err Ct) Taxon trustee (if applicable)
Total 2...
SECTION B.—Taxable Expenditures and Computation of Tax (Section 4952)
@) tem (b) Amount (©) Date pald (@) Name and address of recipient (6) Deseription of expenditure and
1
2
3
4
h) Tax imposed on trustee
(Names of trustees lable for tax (e)Teximposed on trust Te fapplicabe)

(22% of column (b))

Total... ee
Summary of Taxes

1 Enter section 4951 tax on disqualified person (Part !, Section A, column (g))

2 Enter section 4951 tax on trustee (Part |, Section A, column (h))
3 Enter section 4952 tax on trust (Part I, Section B, column (g))

4 Enter section 4952 tax on trustee (Part I, Section B, column (h))

5 Tax due (see instructions). Pay in full with return. Make check or money order "payable to
“Internal Revenue Service.” >

For Paperwork Reduction Act Notice, see page 7 of the instructions tor Form 990-81.