Form 990-BL

(Rev. December 2011) 

Department of the Treasury 

Internal Revenue Service 

Information and Initial Excise Tax Return for Black 

Lung Benefit Trusts and Certain Related Persons 

Under section 501(c)(21) of the Internal Revenue Code. See separate instructions. 

OMB No. 1545-0049 

For calendar year , or fiscal year beginning , , and ending , Name of trust Employer identification number (EIN) of trust 

Name of other person filing return Social Security Number (SSN) or EIN of other filer 

Number, street, and room or suite no. (If a P.O. box, see instructions.) If application pending, check here . . ▶

If address changed, check here . . . ▶

City or town, state and ZIP code FMV of assets at beginning 

of operator’s tax year . ▶

Return filed by (check box that applies): Trust (Open for public inspection—other than Part IV) Trustee (Not open for public inspection) 

Disqualified person (Not open for public inspection) 

Part I Analysis of Revenue and Expenses Revenue 

1 Contributions received . . . . . . . . . . . . . . . . . . . . . . . 1 

2 Investment income: 

a Interest on certain securities of the U.S., state, and local governments . . . . . . . 2a 

b Interest on time or demand deposits in a bank or insured credit union (described in

section 501(c)(21)(D)(ii)(III)) . . . . . . . . . . . . . . . . . . . . . . 2b 

c Gross amount received from sale of assets . . . . . . . .

Less cost or other basis and sales expenses . . . . . . . .

Net gain or (loss) . . . . . . . . . . . . . . . . . . . . . . . . . 2c 

d Other income (attach schedule) . . . . . . . . . . . . . . . . . . . . 2d 

3 Total revenue (add lines 1 through 2d) . . . . . . . . . . . . . . . . ▶ 3 

Expenses 

4 Contributions to the Federal Black Lung Disability Trust Fund . . . . . . . . . . 4 

5 Premiums for insurance to cover liabilities described in section 501(c)(21)(A)(i)(I) and 

501(c)(21)(A)(i)(IV) . . . . . . . . . . . . . . . . . . . . . . . . . 5 

6 Other payments to or for benefit of eligible coal miners, retired miners, or beneficiaries . . 6 

7 Compensation of trustees . . . . . . . . . . . . . . . . . . . . . . 7 

8 Other salaries and wages . . . . . . . . . . . . . . . . . . . . . . 8 

9 Administrative expenses not included on lines 7 and 8 (attach schedule) . . . . . . . 9 

10 Other expenses (attach schedule) . . . . . . . . . . . . . . . . . . . 10 

11 Total expenses (add lines 4 through 10). . . . . . . . . . . . . . . . . . 11 

12 Excess of revenue over expenses (subtract line 11 from line 3) . . . . . . . . ▶ 12 

Part II Balance Sheets Beginning of year End of year Assets 

13 Cash . . . . . . . . . . . . . . . . . . . . . 13 

14 Savings and interest-bearing accounts . . . . . . . . . . 14 

15 Investments in approved securities . . . . . . . . . . . 15 

16 Office supplies and equipment . . . . . . . . . . . . 16 

17 Other assets (attach schedule). . . . . . . . . . . . . 17 

18 Total assets (add lines 13 through 17) . . . . . . . . . . ▶ 18 

Liabilities 

and 

Net Assets 19 Liabilities (see instructions) . . . . . . . . . . . . . . 19 

20 Net assets . . . . . . . . . . . . . . . . . . . 20 

21 Total liabilities and net assets (add lines 19 and 20) . . . . . . ▶ 21 

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10315Y Form 990-BL (Rev. 12-2011) 

The books are in care of ▶ Telephone number ▶

Located at ▶

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 officer or trustee) is based on all information of which preparer has any knowledge. 

Sign 

Here 

▲

▲

Signature of officer or trustee Date 

Type or print name and 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.

May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . . Yes No
Form 990-BL (Rev. 12-2011) Page 2 

Part III Questionnaire Yes No 

22 Have you made any changes not previously reported to the Internal Revenue Service in your governing instrument, 

or other similar instrument? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23 If “Yes,” attach a conformed copy of the changes. 

Taxes on self-dealing (section 4951): 

a During the year did the trust (either directly or indirectly): 

(1) Engage in the sale, exchange, or leasing of property with a disqualified person? . . . . . . . . . .

(2) Borrow or lend money or otherwise extend credit to (or accept it from) a disqualified person? . . . . . .

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? . . . . . . . . .

(4) Pay compensation to, or pay or reimburse expenses of, a disqualified person? . . . . . . . . . . .

(5) Transfer any income or assets to, or for use by or for the benefit of, a disqualified person? . . . . . . .

b If the answer is “Yes” to any of questions 23a(1) through 23a(5), were all of the acts in which you engaged 

excepted acts as described in the instructions? . . . . . . . . . . . . . . . . . . . . . .

c If the answer is “No” to question 23b, complete Schedule A (Form 990-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 benefits for retired miners, 

their spouses, and dependents, (5) permitted investments of trust funds, (6) transfer of funds to the Federal 

Black Lung Disability Fund or to the general fund of the U.S. Treasury, or (7) return of excess contributions to 

the coal mine operator who contributed them?. . . . . . . . . . . . . . . . . . . . . . .

If the answer is “Yes,” complete Schedule A, Form 990-BL, Part I, Section B. 

25 Have you taken corrective action for any transaction that 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 taken and, if applicable, enter 

the fair market value of any property recovered as a result of the correction. ▶ $ 

For any uncorrected acts, attach explanation (see instructions). 

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

(a) 

Name and Address 

(b) 

Title and time 

devoted to position 

(c) Contributions 

to employee benefit 

plans 

(d) 

Expense 

account, other 

allowances 

(e) 

Compensation 

(If not paid, 

enter zero.) 

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Part IV 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? . . . . . . . . . . . . . . . . . .

Yes No 

Form 990-BL (Rev. 12-2011) 
Form 990-BL (Rev. 12-2011) Page 3 

Schedule A—Initial Excise Taxes on Black Lung Benefit Trusts and Certain Related Persons 

Under sections 4951 and 4952 of the Internal Revenue Code 

NOT OPEN FOR PUBLIC INSPECTION 

For the calendar year , or fiscal year beginning , , and ending , 

Name of trust/person filing return (see instructions) 

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

EIN or SSN of filer (see instructions) 

Return filed by (see instructions, check box that applies): Trust Trustee 

Disqualified person 

Part I Initial Taxes on Self-dealing (Section 4951) and Taxable Expenditures (Section 4952) 

SECTION A—Acts of Self-dealing and Tax Computation (Section 4951) 

(a) Act 

number (b) Date of act (c) Description of act 

1 

2 

3 

4 

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

(f) Amount involved in act (g) Initial tax on self-dealing disqualified person 

(10% of column (f)) 

(h) Tax on trustee (if applicable) 

(21⁄2% of column (f)) 

Total (add lines 1 through 4, 

columns (g) and (h)) . . . . . . ▶

SECTION B—Taxable Expenditures and Tax Computation (Section 4952) 

(a) Item 

number (b) Amount (c) Date paid or incurred (d) Name and address of recipient (e) Description of expenditure and purposes for which made 

1 

2 

3 

4 

(f) Names of trustees liable for tax (g) Tax imposed on trust 

(10% of column (b)) 

(h) Tax imposed on 

trustee (if applicable) 

(21⁄2% of column (b)) 

Total (Add lines 1 through 4, columns (g) and (h)) . . . . . . . . . . . ▶

Part II Summary of Taxes 

1 Enter amount of section 4951 tax on disqualified person from Part I, Section A, column (g) 1 

2 Enter amount of section 4951 tax on trustee from Part I, Section A, column (h) . . . . . . 2 

3 Enter amount of section 4952 tax on trust from Part I, Section B, column (g) . . . . . . . 3 

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

5 Total tax due (add lines 1 through 4) . . . . . . . . . . . . . . . . . . . ▶ 5 

Form 990-BL (Rev. 12-2011)