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

(Rev, November 1985) Lung Benefit Trusts and Certain Related Persons OM No 585.089
Pebartinent of the Treasury (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... >
Hfaddress changed, checkhere. .
City or town, state and ZIP code FMV of assets at beginning
of operator's taxyear . >

Return filed by (see General Instruction A and Specific Instruction B, check box that applies):
le aptcoe— Not pen opal oa No pen fr public
C1 Trust mete ei) C1 Trustee“ \ttpecton (1 Disqualified person" nepectan)

Analysis of Revenue and Expenses (see instructions)

1 Contributions received . . al
2 Investment income: Ms
a Interest on certain securities of the U.S., state, andlocalgovernments . . . . . 2a
g b Interest on time or demand deposits in a bank or insured credit union (described in section |
S 5O1(c21(BMiiINM)) . ee . | 2b
>
2 ¢ Gross amount received from sale of assets re [——_——_~ Y/
Minus cost or other basis andsalesexpenses. . . . . . . . Uj
Net gain or (loss) Le 2c
d Otherincome(attachschedule) 2. el De
3 Total revenue (addlines 1through2d) . ww. . rr 3
4 Contributions to the Federal Black Lung Disability Trust Fund _ sae. b4
5 Premiums for insurance to cover liabilities described in section 501(cX21KAN)_ re oo
3 6 Other payments to or for benefit of eligible coal miners or beneficiaries . . . . . 2. . 6
5 7 Compensation of trustees . 7
2 8 Other salaries and wages 8
uw 9 Administrative expenses not included on lines 7 and 8 (attach schedule) . 2. Lo
10 Other (attach schedule) Se
11 Total expenses (add lines 4 through 10) |. |, woe Pd
12 Excess of revenue over expenses (subtract line 1] from Ine 3). woe ee 11
| Part 11] Balance Sheets : Beginning of year End of year
13Cash . . . . See ee ee ee LS
2 14 Savings and interest bearing accounts a
g 15 Investments inapprovedsecurities. . . ........ .{ 35
2 16 Office supplies andequipment . . . . . 2... . . . . 36
17 Other (attach schedule). ce ee ee ee PAZ
18 Total assets (add lines 13 through 17)" Fr a Oe )
£] 19 Liabilities(see instructions)... ........... (29
ts 20 Networthorcapitalaccount. . ............ (C20
>
Zz 21 Total liabilities and net worth (add lines 19and20)_. . . . . » | 21

The books are in care of >
Located at >

Telephone number » (_

Pl Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
ASE | belies, 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
Paid ,.[_ Signature
Prepatet’s!~Firms name (or
Use Only | yours, if self-employed)

and addres ZIP code
For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 990-BL (Rev. 11-85)



Form 990-BL (Rev. 11-85)

Page 2

j Part 111] 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? . toe
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?
(2) Borrowing or lending of money or other extension of credit? .
(3) Furnishing of goods, services, or facilities?
(4) Payment of compensation (or payment or reimbursement of expenses)? soe .
(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 23a(1) through 23a(5) is answered ‘‘Yes,"’ were all of the acts in which you engaged excepted acts
described in the instructions?
¢ If 23bis ‘‘No," complete Schedule A (Form 9904 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, (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 |, Section B.
25 Has corrective action been taken with respect to any transaction which resulted in Chapter 42 taxes Pein reported on
Schedule A (Form 990-BL)? .

If “Yes,"’ attach a detailed documentation and description o! of the corrective action n taken and, ‘if applicable, enter sr the fair

market value of any property recovered as a result of the correction » $ (for any uncorrected acts,

attach explanation (see instructions)).

Mh

Y) -

TM

i

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

Title and time Contributions [Expense account,

Name and Address devoted to position

benefit plans allowances

toemployee other Compensation

Total.

izlighg 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? se ws woe



eae poo.nL) Computation of Initial Excise Taxes on OMB No. 154 0049
(Rev. November 1985) Black Lung Benefit Trusts and Certain Related Persons | NOT Open fo Open for
Department of the Treasury (Under sections 4951 and 4952 of the Internal Revenue Code) 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):

O Trust © Trustee 1 Disqualified person

EEG] initial Taxes on Self-dealing (Section 4951) and Taxable Expenditures (Section 4952)
SECTION A.—Acts of Self-dealing and Tax Computation (Section 4951)

saaber (b) Date of act (©) Description of act

oO

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

js i Initial tax on self-dealing disqualified (h) Tax on trustee (if applicabl
(f) Amount involved in act @ on gelt-dealing disqualified person (h) axon tus te (applica le)
Total 2. 2 ww ee ee
SECTION B.—Taxable Expenditures and Computation of Tax (Section 4952)

(@) item (b) Amount (6) Date paid (€) Name and address of recipient (6) Description of expenditure and
1
2
3 -
4

(h) Tax imposed on trustee
(if applicable)
(214% of column (b))

(g) Tax imposed on trust

(f) Names of trustees liable for tax 110% of column (b))

Total . . - Ld
| Part 1] Summary ofTaxes

1 Enter section 4951 tax on disqualified person (Part |, Section A, column (g))

2 Enter section 4951 tax on trustee (Part I, Section A, column (h))
3 Enter section 4952 tax on trust (Part |, Section B, column (g))

4 Enter section 4952 tax on trustee (Part I, SectionB,column(h)) . . 2... we
5 Tax due (see instructions). Pay in full with return. Make check or money order r payable te
“Internal Revenue Service."” :

For Paperwork Reduction Act Notice, see page 1 of the instructions for Form m990- BL.