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

(Rev. April 1991) Lung Benefit Trusts and Certain Related Persons — | 0M®Ne 15450049
(See separate instructions.) xpires
Department of the Treasury
internal Revenue Service (Under section 501(c)(21) of the Internal Revenue Code)
For calendar year 19 _ or fiscal year beginning 19 and ending 119
(See General Instruction A and the Specific Instructions for completing the heading.)
Name of trust Employer identification number of trust
Name of other person filing return Social security or E.I. no. of other filer
Address of filer (number, street, room, or P.O. box number) {f application pending, check here. . ®OI
If address changed, checkhere. . . LJ
City or town, state and ZIP code FMV of assets at beginning
of operator's tax year.

Return filed by (check box that applies)
(Ope for pubic nspection — fr public Not open fr publi
CO Trust athe than Far) Ctrustee \npecion ( Disqualified person “*\itpetin)

| Part |] Analysis of Revenue and Expenses (see instructions)

1 Contributions received . . be 1
2 Investment income: M,
a Interest on certain securities of the U.S., state, and local governments . . . . 2a

b Interest on time or demand deposits in a bank or insured credit union (described in \ section
501(c(21 (BM)... Fee oe Leb

¢ Gross amount received from sale of assets Soe 7]
Minus cost or other basis and sales expenses. . . toe 7],

Net gain or (loss) . 2c

d_ Other income (attach schedule) . Soe Soe 2d

3 Total revenue (add lines 1through 2d)... . ee ee)
4 Contributions to the Federal Black Lung Disability Trust Fund . . . . Loe 4
5

| 6

7

8

9

Revenue

5 Premiums for insurance to cover liabilities described in section 501(c\(21)(AXi)_
6 Other payments to or for benefit of eligible coal miners or beneficiaries

7 Compensation of trustees

8 Other salaries and wages

Expenses

9 Administrative expenses not included on vines 7 and 8 (attach schedule) . .
10 Other expenses (attach schedule) Co woe ee ee £10
11 Total expenses (addlines4through10) . . . - ee ae 2S
12 Excess of revenue over expenses (subtract line 11 from ‘ine 3) om 112

| Part 11] Balance Sheets Beginning of year End of year

13Cash . . Se . 13
a 14 Savings and interest- bearing accounts Foe Loe 14
9 15 Investments inapprovedsecurities . . . 2... 1 15
a 16 Office supplies and equipment Se . 16
17 Other assets (attach schedule) . Soe 17
18 Total assets (add lines 13 through 17), . oe ee | 1B
19 Liabilities (see instructions). . Co 19
20Netassets. 2. ee ee ee | 20

21 Total liabilities and net assets (addlines19and20)_. > | 21

The books are in care of >
Located at >

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 | belief, itis true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign y )
Here Signature of person filing return Date Title

. Preparer's Date
Paid [Signature
Prepater’s Firs name (or
Use Only | 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. 4-91)


Form 990-BL (Rev. 4-91)

Page 2

Questionnaire Yes | No
22 Have any changes not previously reported to the Internal Revenue Service been made in your governing instrument, or MI
other similar instrument? . :- to
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)X— Uh
(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)? . :
(5) Transfer to, or use by or for the benefit of, a disqualified person of any part of your income or sr 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 Mh

as described in the instructions?
c 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 I, Section B.

I

25 Has corrective action been taken with respect to any transaction which resulted in Chapter 42 taxes being reported on Ys
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:
ry l © @ @)
@) Title ard time Contributions | Expense account, | Compensation
Name and Address to employee other (if not paid,
devotedtoposition | benefit plans | allowances enter zero)
Total... ee
ixl4ahg 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
Yes| No

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?



SCHEDULE A

Computation of Initial Excise Taxes on eee rele
(Form 990-BL)

(Rev, April 1991) Black Lung Benefit Trusts and Certain Related Persons NOT Open for
Pepartment of the Treasury (Under sections 4951 and 4952 of the Internal Revenue Code) Public Inspection
For the calendar year 19 _or fiscal year beginning 119 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 C1 Trustee C1 Disqualified person

| Part || Initial Taxes on Self-dealing (Section 4951) and Taxable Expenditures (Section 4952)
SECTION A.—Acts of Self-dealing and Tax Computation (Section 4951)

Mamaber| (0) Date of act (©) Description of act

1
2
3
4

(e) Names of trustees liable for tax

(g) Initial tax on self-dealing disqualified person (n) Tax on trustee (if applicable)
(f) Amount involved in act (10% of column (9) (24% of column (f))

Total... >
SECTION B.—Taxable Expenditures and Tax Computation (Section 4952)
fiimber| Amount | CN ireunred (4) Name and address of rei (© Ppurpeses for which made
1
2
3
4

(h) Tax imposed on trustee
(if applicable)
(244% of column (b))

(f) Names of trustees liable for tax Ors imposed ht trust

Total. 2. ee

i<laaig Summary of Taxes

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

2 Enter section 4951 tax on trustee (Part |, Section A,column(h)) . . . . . . re a3

3 Enter section 4952 tax on trust (Part |, Section B, column(g)). . 2... ee ee ee FS

4 Enter section 4952 tax on trustee (Part I, Section B, column (h)) 4

5 Tax due (see instructions). Pay in full with return, Make check or money order F payable to
“Internal Revenue Service.’ : >| 5

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