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

(Revised October 1981) Lung Benefit Trusts and Certain Related Persons OMB No, 1545-0049
Depar -
Intra Revenue Service (Under section 501(c)(21) of the Internal Revenue Code)
For calendar year 19 __, or fiscal year beginning 119, 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 D>

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

- (Open for public inspec (Not open for public i Not open for publi
[] Trust fion--other than Part IV) (] Trustee M\inspection) [) Disqualified person (Not open fea pyene

Analysis of Revenue and Expenses (see instructions)

1 Contributions received © © 2). ee ef
2 Investment income: 2 WYWWWW§I,
(a) Interest on certain securities of the U.S., and State and local governments. . . . 2(a)
. (b) Interest on time or demand deposits in a bank, or insured credit union (described in section
3 501(c)(21)(B)(ii)(II)). ee a  (:))
& (c) Gross amount received from sale of assets. . . . 2. 2... Y
Minus cost or other basis and sales expenses. . . . . 2. 1. Y Yj Vj
Net gain or (loss). 6. ew ee ee [20D
(d) Other income (attach schedule) . ee ee 2D
3 Total revenue (add lines 1through2(d)). . . . . .
4 Contributions to the Federal Black Lung Disability Trust Fund . re
5 Premiums for insurance to cover liabilities described in section 501(c)(21)(A)(i « re
2 6 Other payments to or for benefit of eligible coal miners or beneficiaries . ca
2 | 7 Compensation of trustees 7
5 8 Other salaries and wages . 8
9 Administrative expenses not included on lines 7 and 8 (attach schedule) . re
10 Other (attach schedule). . 20
11 Total expenses (add lines 4 through 10)... ee, 11
12 Excess of revenue over expenses (subtract line 11 fromline 3)... = {12
Part I Balance Sheets Beginning of year End of year
13 Cash... . . i
14 Savings and interest ‘bearing a accounts. . . . .. .. .. . , {24_)
2 | 15 Investments in approved securities . 15
2 | 16 office supplies andequipment. . . . 2... ee . (LO
17 Other (attach schedule) . . a FA
18 Total assets (add lines 13 through 17)... - ee 1B
g| 19 Liabilities (see instructions). . . 2 2. 1 2 we we. [a9
ZS} 20 Net worth or capital account. . . 2 2 2.) 1 ee wee. 120
ou
~ =| 21 Total liabilities and net worth (add lines 19 and 20)... . . . . & [21
The books are in care of D> Telephone number Pe (..._.)..

Located at >

Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my

Please knowledge and belief, it 1s true, correct, and complete. Declaration of preparer (other than taxpayer) 1s based on all information of which preparer
: has any knowledge.
Sign
Here — —— a ee a
Signature of person filing return Date Title

Preparer’s Date

Paid signature >
1

Preparer’s Firm's name (or
Use Only yours, if self-employed)

and address ZIP code >

For Paperwork Reduction Act Notice, see page 1 of the instructions Form 990—BL (Rev. 10-81)


Form 990-BL (Rev. 10-81) Page 2

[2am 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? . .
If “Yes,” attach a conformed copy of the changes.

23 Self-dealing (section 4951): _

No

Wi

(a) Have you engaged in any of the following acts during the year either directly or indirectly, with one or more disqualified _
4.

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 f expenses)? a .
(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? .

(c) !f (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, (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)? .

I "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 tlie correction Pe $......... vossocsussuss (for any uncorrected acts,

attach explanation (see instructions).
26 Officers, directors, trustees and their compensation, if any, for the tax year:

|

Contributions | Expense ac-
Name and Address Title and time to employee | count, other Compensation
devoted to position | benefit pians | ‘allowances

Total... wee . re 2
HEZGATM Statement With Respect to Contributors, etc. (Not o 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 |_Yes_|_No_

for the contributor under section 192?



SCHEDULE A Computation of Initial Excise Taxes on OMB No. 1545-0049
(Form 990-BL)

(Revised October 1981) Black Lung Benefit Trusts and Certain Related Persons NOT Open for
Department of the Ti j 4 °
internal Revenue Service (Under sections 4951 and 4952 of the Internal Revenue Code) Public Inspection
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):
(J Trust (] Trustee [J 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)

a. Act ~
number b, Date of act c, Description of act

RANE

d. Names of disqualified persons liable for tax e. Names of trustees liable for tax

& Initial tax on ssif-dealing disqualified person h. Tax on trustee (if applicable)

f. Amount involved in act oe oF column Cuan Hee

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

a. Item ¢. Date paid 5
b. Amount c. Date paid d. Name and address of recipient

e. Description of expenditure and
number

purposes for which made

PAD H

g. Tax imposed on trust h. Tax imposed on trustee

#. Names of trustees liable for tax (10% of column b) Q%% BP ecolursn b)

Total . . re 2
Part Il Summary of Taxes

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

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

3 Enter section 4952 tax on trust (Part I, Section B, column g) .

4 Enter section 4952 tax on trustee (Part I, Section B, column h) . .
..5 Tax due (see instructions). Pay in full with return. (Make check or money order payable to
“Internal Revenue Service.) . . . Peel a 2
For Paperwork Reduction Act Notice, see page 7 of the instructions Tor F Form 990-BL.

US GOVERNMENT PRINTING OFFICE: 1981-343-369/1D-14-1538075,