Information and Initial Excise Tax Return for Black

Lung Benefit Trusts and Certain Related Persons

Form 990-BL

OMB No. 1545-0049 (Rev. January 1997)

Department of the Treasury

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

For calendar year 19 , or fiscal year beginning , 19 , and ending , 19

Name of trust Employer identification number of trust

Name of other person filing return Social security or E.I. no. 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):

Disqualified person (Not open for public inspection)

Trust (Open for public inspection—other than Part IV) Trustee (Not open for public inspection)

Analysis of Revenue and Expenses

1 Contributions received 1

2 Investment income:

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

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

section 501(c)(21)(D)(ii)(III))

b

2b

c Gross amount received from sale of assets

Revenue

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

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

Expenses

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

Balance Sheets Beginning of year End of year

13 Cash 13

14 Savings and interest-bearing accounts 14

15 Investments in approved securities 15

16 Office supplies and equipment 16

Assets

17 Other assets (attach schedule) 17

18 Total assets (add lines 13 through 17) © 18

19 Liabilities (see instructions) 19

20 Net assets 20

Liabilities

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

and

Net Assets

( ) The books are in care of © Telephone number © 

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

Preparer’s Date

Paid signature

Preparer’s

Use Only

©

Firm’s name (or

yours, if self-employed)

and address © ZIP code

For Paperwork Reduction Act Notice, see page 1 of the instructions. Cat. No. 10315Y Form 990-BL (Rev. 1-97)

Part I

Part II

Located at ©
Form 990-BL (Rev. 1-97) Page 2

Questionnaire Yes No

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

or other similar instrument?

22

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

23 Taxes on self-dealing (section 4951):

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

(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?

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

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?

b

c If the answer is “No” to question 23b, complete Schedule A (Form 990-BL), Part I, Section A.

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?

24

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:

(e)

Compensation

(If not paid,

enter zero.)

(d)

Expense

account, other

allowances

(c)

Contributions

to employee

benefit plans

(b)

Title and time

devoted to position

(a)

Name and Address

Total ©

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

During the period covered by this return did the trust receive any contributions in excess of the maximum Yes No

allowable deduction for the contributor under section 192?

2

Part III

Part IV

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

Disqualified person

Trustee

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

(g) Initial tax on self-dealing disqualified person

(10% of column (f))

(h) Tax on trustee (if applicable)

(21⁄2% of column (f)) (f) Amount involved in act

Total (add lines 1 through 4,

columns (g) and (h)) ©

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

(e) Description of expenditure and

purposes for which made

(a) Item

number

(c) Date paid

or incurred (b) Amount (d) Name and address of recipient

1

2

3

4

(h) Tax imposed on

trustee (if applicable)

(21⁄2% of column (b))

(g) Tax imposed on trust

(10% of column (b)) (f) Names of trustees liable for tax

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

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 Tax due © 5

For Paperwork Reduction Act Notice, see page 1 of the instructions for Form 990-BL.

Part I

Part II