rom 6069 Return of Excise Tax on Excess Contributions to OMB No, 1545,0049
(Rev. Novernber 1985) Black Lung Benefit Trust Under Section 4953 and = |———"~__
Department of the Treasury Computation of Section 192 Deduction NOT Open for

Internal Revenue Service Public Inspection

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

Operator's name | Employer identification number

Address (number and street)

WW address changed, checkhere . . . . . & LI

City or town, state and Zip code

Name of related section 501(c\21) trust Employer identification number of related trust

SrTmcey Worksheet for Computing the Section 192 Deduction by Coal Mine Operators

1 Enter the amount necessary to fund (with level funding) the remaining unfunded liability for claims filed
or expected to be filed by, or on behalf of, past or present employees of the operator based on:

a The average remaining working life of miners currently employed ja
b 10 tax years : ib
¢ Any other funding period peserbedo or soproved byt the Secretary of
the Treasury . Le
a Enterthe smaller oflinelaorlb. . ... ....... Lad Ms
e Enter the larger of line 1c or 1d . le
2 a Enter the amount necessary to carry out section s0uoeD9
purposes forthe taxyear. . . . 2a
b Enter the fair market value of the trust for the y year (ee ‘instructions) 2b Ms
c Subtract line 2b from line 2a (if less than zero enter zero) . 2c
3 Maximum allowable deduction (enter the larger of line leorline 2c)... >l13

Satis) Computation of Section 4953 Tax by the Person Making Excess Contributions Under Section 192 toa
Section 501(c)(21) Trust

1 a Contributions made to section 501(c)(21) trust for operator’s tax year ja
b Operator's maximum allowable deduction under section 192 for tax

year (enter amount from Schedule A, line3) . . . 2. eee 1b
¢ Excess of line 1a over line 1b (if less than zero enter zero). . . . L1¢
2 Excess contributions from precedingtaxyear. . . . ..... L2 Mi
3 Total(addlinestcand2) 2. ee LB

4 Amount that current year’s contributions are less than the maximum amount

deductible (subtract line 1a from line 1b)(if less than zeroenter zero) . . 4
5 Amount of previous year's excess contributions that were returned to the 5 ]f Tf] ]
contributor... rs Mj

6 Total (add lines 4 and 5) . Ce ee ee ee LG
7 Excess contributions for current year (subtract line 6 from line 3)(if less than zero enter zero) . 7
8 Tax due (enter 5% of line 7). Payin in full with return. n (Make check or money order payable to “Internal
Revenue Service.”) . ee ee)
Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge and

Please belief, itis true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here » »—

e Signature of person filing return Date 7 Title

5 Preparer’s » Date
Paid signature
Preparer's

Firm's name (or yours, >

Use Onl if self-employed) and
Y | address ZIP code

For Paperwork Reduction Act Notice, see instructions on the back of the return. Form 6069 (Rev 11-85)


Form 6069 (Rev. 11-85)

Page 2

General Instructions

(Section references are to the Internal
Revenue Code, unless otherwise noted.)
Paperwork Reduction Act Notice.—We
ask for this information to carry out the
Internal Revenue laws of the United States.
We need it to ensure that you are complying
with these laws and to allow us to figure and
collect the right amount of tax. You are
required to give us this information.
Purpose.—Form 6069 is primarily a
worksheet (Schedule A) used to determine
the maximum allowable income tax
deduction (under section 192) for
contributions made by coal mine operators
to tax-exempt black lung benefit trusts. The
form is also used to determine the amount
of excise tax imposed under section 4953
for contributions that are more than the
maximum allowable deduction

Who Must File.—Any person who has
incurred liability for the excise tax on excess
contributions under section 4953 must file
a return on Form 6069. File Form 6069
only to report the excise tax liability figured
on Schedule B. Do not file it when only
Schedule A is completed.

When and Where to File.—If you are
required to file Form 6069, you must file it
by the 15th day of the 5th month after the
end of your tax year. File it with the Internal
Revenue Service Center, Cincinnati, OH
45999.

If you need more time, you may file Form
2758, Application for Extension of Time to
File, to request an extension of time to file
Form 6069.

Accounting Methods.—Use the
accounting method regularly used in
keeping your books and records.
Accounting Period.—Complete the return
‘on the basis of your established accounting
period. If you do not have an established
accounting period, use the calendar year.
Penalties and Interest.—There are
penalties for late filing, willful failure to file,
and for filing fraudulent returns and
statements. See sections 6651, 7203,
7206, and 7207.

Interest at the annual rate provided by
law is charged on any tax shown on line 8,
Schedule B, that is not paid by the due date
of the return.

Definitions

The term “Black Lung Acts” refers to Part C
of Title IV of the Federal Coal Mine Health
and Safety Act of 1977, and any State law
that provides compensation for disability or
death due to pneumoconiosis (black lung
disease). A black lung benefit claim is a
claim for compensation for disability or
death due to pneumoconiosis under the
Black Lung Acts

Unless otherwise indicated, the term
“trust” as used in the instructions means
the tax exempt section 501(c)(21) trust or
trusts to which you made contributions for
which you claimed a deduction under
section 192.

Specific Instructions

No deduction will be allowed under section
192(a) for any contribution to a trust other
than a contribution in cash or in items in
which the trust may invest under section
501(c)(21)(B)(ii).

Payments made on account of a
particular tax year that are made no later
than the due date (including extensions) of
your income tax return for that tax year will
be considered to have been made on the
last day of that tax year.

Period to be Covered by Return.—Fill in
the spaces at the top of the form to show
the calendar year or fiscal year of the
accounting period you are reporting.

Name and Address.—Enter your name,
address, and employer identification
number in the appropriate spaces. In the
spaces for the name and employer
identification number of the related trust,
enter the identifying information for the
black lung benefit trust to which you made
excess contributions.

Rounding Off to Whole-dollar
Amounts.—You may show the money
items on the return and accompanying
schedules as whole-dollar amounts. To do
so, drop any amount less than 50 cents and
increase any amount from 50 cents through
99 cents to the next higher dollar.
Schedule A

Line 1.—The determination of amounts
necessary to cover payments for claims
made under the Black Lung Benefits Acts of
1977 must be based on reasonable
actuarial assumptions consistent with
regulations to be issued by the Secretary of
the Treasury. On lines 1a, 1b, and 1c enter
the annual amounts you need to fund (with
level funding) all claims against you that
were filed, or expected to be filed by, or on
behalf of, past or present employees for
compensation because of disability or
death, due to pneumoconiosis, under the
Black Lung Acts.

Line 1e.—Enter the largest amount you
expect to need to pay claims against you
using one of the projections on line 1c or 1d.
Line 2a.—Enter the total amount paid
during the year for any combination of the
following:

@ Alladministrative and other incidental
expenses of operating the trust and
processing claims against you (including
legal, actuarial, and trustee expenses).
 Alldirect payments by the trust for
claims against you.

e All payments of premiums exclusively for
insurance to cover your liability for claims
filed under the Black Lung Acts.

Line 2b.—Enter the fair market value of
the trust's assets at the beginning of your
tax year.

Line 3.—Enter the amount from line le or
2c, whichever is larger.

If you are completing Schedule A only to
figure the maximum allowable deduction
and do not owe tax on excess contributions,
keep this form instead of filing it with IRS.

Schedule B

Complete Schedule B only for tax years in
which your contributions to black lung
benefit trusts are more than the maximum
allowable deduction under section 192.
Line 1a.—Enter the amount contributed to
section 501(c)(21) trusts for the year.

Line 1b.—Enter the amount from line 3,
Schedule A of Form 6069.

Line 1c.—Subtract line 1b from la.

Line 2.—If you made contributions for a
tax year under section 192(a) that totaled
more than the maximum allowable
deduction under section 192(b) for that tax
year, the excess is carried over to the next
tax year and treated as a contribution to the
trust in that tax year. Enter any excess
contributions from the previous year's
Schedule B, Form 6069.

Line 4.—Enter the amount by which line
1b is more than 1a or zero.

Line 5.—If you made excess contributions
to a black lung benefit trust for a tax year,
the trust will, at your request, repay the
amount of the excess contributions, but not
more than the excess. The payment will not
be an act of self-dealing or a taxable ex-
penditure, but the repayment does not
remove your liability for the tax on excess
contributions. Enter any excess contribu-
tions from the previous year's Form 6069
that the trust returned to you.

Line 8.—Enter 5% of the amount on line 7.

Signature

If you are filing for a corporation, the return
must be signed by the president, vice
president, treasurer, assistant treasurer,
chief accounting officer or any other officer
(such as tax officer) authorized to sign. If
you are filing for a partnership, one general
partner must sign. If you are filing for a sole
proprietorship, the owner must sign.

Ifa receiver, trustee in bankruptcy, or
assignee is in control of the operator's
property or business, that person must sign
the return.

The return must also be signed by any
person, firm, or corporation who prepared
the return. If the return is prepared by a
firm or corporation, it should be signed in
the name of the firm or corporation. The
signature of the preparer is not required if
the return is prepared by your regular, full-
time employee.