rom 990-BL Information and Initial Excise Tax Return for Black

(Revised December 1982) Lung Benefit Trusts and Certain Related Persons OMB Wo, 1545-0089
eet ease (Under section 501(c)(21) of the Internal Revenue Code) Expires 11-30-85
For calendar year 19 or fiscal year beginning 19 ,and ending 19.
Name of trust Employer identification number (see instructions)
Name of other person filing return (see instructions) Social security n number (see instructions)
Address of filer (number and street) 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 (see General Instruction A and Specific Instruction B, check box that applies):

(Open for public inspec: Not open for publi >P
[I Trust (2pe" heP than Part WV) [J Trustee (Not open for public [J Disqualified person (Net open for public

Analysis of Revenue and Expenses (see instructions)

1 Contributions received ©. 6 - ee ee
2 Investment income:

(a) Interest on certain securities of the U.S., and State and local governments .

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

|
= MTU

I 501(c)(21)(B)IN). Se ee 2(b) D
(©) Gross amount received from sale of assets . 7
Minus cost or other basis and sales expenses. . . 2. . + + e 7 —Y)
Net gain or (loss). ee ee [2
(d) Other income (attach schedule). © 6 6 ee ee ee ee ee (2D

3 Total revenue (add lines 1 through 2(d)). . . . ree on )
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) . _5_|
6 Other payments to or for benefit of eligible coal miners or beneficiaries . <a
Hy 7 Compensation of trustees Ce ee LT
& 8 Other salaries and wages . . . coe ee ee LB
9 Administrative expenses not included on lines 7 and 8 (attach schedule) . toe |_9 |
10
Pat |
12

10 Other (attach schedule) . So ee
11 Total expenses (add lines 4 through 10)... . wee ee

MTT TT

12 Excess of revenue over expenses (subtract line 11 from line 5 >!
Part Il Balance Sheets Beginning of year End of year
13 Cashes. 13.
14 Savings and interest bearing a accounts . 14
j 15 Investments in approved securities. . . . .. 2... . . «435
16 Office supplies and equipment . 16
17 Other (attach schedule) » re i
18 Total assets (add lines 13 through 17)... | a8
o 19 Liabilities (see instructions). . . . . . 1... ee ee ss [ad
3
a3 20 Net worth or capital account. . . . . . - 2. ee eee | 20
a 21 Total liabilities and net worth (add lines 19 and 20)... . - - . & | 21

The books are in care of D> Telephone number >

Located at D>
‘Under penalties of perjury, 1 declare that | have examined this return, including accompanying schedules and statements, and to the best of my
Please knowledge and belie, itis 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
Preparer’s Date

mia | sae’

.,

Preparer'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. 12-82)



Form 990-BL (Rev. 12~82)

GUE Questionnaire

22 Have any changes not previously reported to the Internal Revenue Service been made in your governing instrument, or other
instrument of similar import?. . 6 6 ee ee ee
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) —
(1) Sale, exchange, or leasing of property?. . . So ee ee
(2) Borrowing or lending of money or other extension of credit? .
(3) Furnishing of goods, services, or facilities?. . . ee
(4) Payment of compensation (or payment or reimbursement of expenses)? « er er re
(5) Transfer to, or use by or for the benefit of, a disqualified person of any part of your income or assets? .

(b) If any of questions 23(a)(1) through 23(a)(5) is answered “Yes,” were all of the acts in which you engaged excepted
acts described in the instructions?. . . oe i

(c) If (b) is “No,” complete Schedule A (Form 990-B1), Part |, 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 cotrective action been taken with respect to any transaction which resulted in Chapter 42 taxes being reported on Sched-
ule A (Form 990-BL)? 66 ek te
If “Yes,” attach a detailed documentation and description of the corrective action taken and, if applicable, enter the fair

.. (for any uncorrected acts,

market value’of any property recovered as a result of the correction >> $..
attach explanation (see instructions)).  - ‘
26 Officers, directors, trustees and their compensation, if any, for the tax year:

\\ HS

Ler i

me UE

Contributions Expense ac-
Title and time
Name and Address devoted to position | £2, emr count, other Compensation
Total... - : wee et re 2
[Zualae Statement With Respect to Contributors, etc. (Rote open for “public inspection)
1 Persons who contributed $5,000 or more in the tax 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 1927... es ee es

Yes



aan A ) Computation of Initial Excise Taxes on Hechter aad

rm . . je
(Revised December 1982) Black Lung Benefit Trusts and Certain Related Persons NOT Open for
Internal Revenue Seni” (Under sections 4951 and 4952 of the Internal Revenue Code). Public Inspection
For calendar year 19 , or fiscal year beginning 19 and ending 19 .
Name of trust/person filing return (see instructions) Employer identification number or social

security number of filer (see instructions)

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

Return filed by (see instructions, check box that applies):
(J Trust [] 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)

nurnber b. Date of act ¢. Description of act
1.
2.
B..e
4.
d, Names of disqualified persons liable for tax e. Names of trustees liable for tax

th g. Initial tax on self-dealing disqualified person h. Tax on trustee (if applicabl
f. Amount involved in act 40% ofcolumn Car he ali

Total... ee ee
SECTION B.—Taxable Expenditures and Computation of Tax (Section 4952)
Bamber b. Amount ©, Date paid d. Name and address of recipient ©: Description of expenditure and
1
2 .
3
4. oa
i h. Tax imposed on t
i Tax imposed on trust
f. Names of trustees liable for tax & Tax imposed on tru eee rial o

Total... re 2
Part Il. Summary of Taxes
1 Enter section 4951 tax on disqualified person (Part 1, Section A, columng). . . . . . + +

2 Enter section 4951 tax on trustee (Part I, Section A, column hy). . 2... ee ee ee

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

4 Enter section 4952 tax on trustee (Part I, Section B, column hh). . . . 2 6 we ew .
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 1 of the instructions for Form 990-BL.
AUS COVERNMENT PRINTING OFFICE:1983~381-108/75