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

(Revised October 1979) Lung Benefit Trusts and Certain Related Persons
cee cue series (Under section 501(c)(21) of the Internal Revenue Code)
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 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 taxable year >

Return filed by (see General Instruction A and Specific Instruction B, check box that applies):

Cl Trust (Qpen or public inspec; i] Trustee (Notapentee public] Disqualified person “Net pen er public

HEE Analysis of Revenue and Expenses

1 Contributions received . 2 2 2 2 ee we ee ee ee ee
2 Investment income:
(a) Interest on certain securities of the U.
(b) interest on time or demand deposits

, and State and local governments (see instructions). . .
a bank, or insured credit union (described in section 501(c)

2
5 (21)(B)(i) (I). sh oe ; . : ee ee Dy Yi ;
2 (c) Gross amount received from sale of assets. . 2 1. se ee YY
. Minus cost or other basis and sales expenses. . . . . - . | V7

Net gain or (loss). - ee ee ee eee ee eh Ce ry

(d) Other income (attach schedule). . 2 2 - 2 6 2 ee ee eee wo

3 Total revenue (add lines 1 through 2(d)) . . - ee we ee ee ee ee ee

4 Contributions to the Federal Black Lung Disability Trust Fund. . 6. 2 6 ee ee ee ee

5 Premiums for insurance to cover liabilities described in section 501(c)(21)(A)(i) (see instructions) . .

6 Other payments to or for benefit of eligible coal miners or beneficiaries. . . . 2. 2. 2. 2 ew ee

7 Compensation of trustees. 2 6 6 6 6 ee ee ee ee ee ee et

8 Other salaries and wages. . . - «© 6 se . oe ey

9 Administrative expenses not included on lines 7 and 8 (attach schedule) eee ee ee ee a

10 Other (attach schedule). . . Sr

11 Total expenses (add lines 4 through’ 10). eee ee ee ee ew ww we

12 Excess of revenue over expenses (subtract line 11 from line 3) . . . ......4.,.2.~2. >
Balance Sheets Beginning of year End of year

13 Cash. 6 ew we eww ee we ew wt hh ee
14 Savings and interest bearing accounts. . . 2. 2 6 2 2 ee ee ee
i 15 Investments in approved securities . . 2. 2 2 2 2 es es we te ee ee

16 Office supplies and equipment. . 2. 2 2 2 2 6 8 ee ee ee ee
17 Other (attach schedule). . . . CY

18 Total assets (add lines 13 through 1)
€ 19 Liabilities (see instructions). . . 6. 6 6 6 es 8 ee ee ee
= 20 Net worth or capital account . eo eee ee ee
=| 21 Total liabilities and net worth (add lines 19 and 20)... - ss ee

The books are in care of > ____ . Telephone number > (.

Located at >
ler penalties of perjury, ! deciare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge
Sng. belief it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on ail information of which the preparer has any knowledge.

oo ‘of person filing return Date — ‘Signature

Please Sign Here

Drs Drsscnre address (or employer's name and address)
Form 990—BL (Rev. 10-79)



Form 990-BL (Rev. 10-79)

Page

Nn

[ZS Questionnaire

Yes

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 ee 8 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?. . . . . . | eee . . .
(2) Borrowing or lending of money or other extension of credit?. . . . . . . ee ee
(3) Furnishing of goods, services, or facilities?. . . . 6. 6 2 6 2 ee ee st ot ee
(4) Payment of compensation (or payment or reimbursement of expenses)?... . 2 6 6 2 ee ee ee

(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?. 2. 6-6 ee ee ee ee ee he ee ee ee
(c) If (b) is “'No,"’ 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 investments of trust funds, or (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 Sched-
ule A (Form 990-BL)? . . 6 ee ee ee ee
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 taxable year:

NY

HTT as

LU

aa

N
N

Z

\

Title and time Contributions | Expense ac-

Name and Address devoted te position | £2 employee | count, other Compensation

benefit plans | allowances

Total... ee ee ee

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 1927 . . . . ww ee : : : : .



SCHEDULE A Computation of Initial Excise Taxes on

(Form 990—BL) 7 ' NOT Open for
(Revised October 1279) Black Lung Benefit Trusts and Certain Related Persons Public Inspection
jepartment of th

Internal Revenue Service (Under sections 4951 and 4952 of the Internal Revenue Code)

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):
( 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)

number b, Date of act . Description of act
1...
2
3. :
4 +
d. Names of disqualified persons liable for tax e. Names o* trustees liable for tax

- Initial tax on self-dealing disqualified person h, Tax on trustee (if applicabte)
f. Amount involved in act 10% of column }) (206% of column f)

Total. . «. . -
SECTION B.—Taxable Expenditures and Computation of Tax (Section 4952)

2, Iter b. Amount & Date pald 4. Name and address of recipient ¢. Description of expenditure and
1. .
2. .
3. .
4. .
fh. Tax imposed on trustee
f. Names of trustees liable for tax © Tax imposed on trust epepcable)

Total... eee

Summary of Taxes

1 Enter section 4951 tax on disqualified person (Part I, Section A,columng). . . ee
2 Enter section 4951 tax on trustee (Part I, Section A, column h) « Pry .
3 Enter section 4952 tax on trust (Part , Section B, column g) . oe
4 Enter section 4952 tax on trustee (Part I, Section B, column hh). «6 6 6 we ee

5 Tax due (see instructions). Pay in fuli with return. (Make check or money order payable to
“Internal Revenue Service. :

‘Ye US, GOVERNMENT PRINTING OFFICE : 1979~-O-283-21523-0916750