Form 990-BL and Schedul 990-BL and Schedul Information and Initial Excise Tax Return for Black Lung

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 990-BL, PAGE 1 OF 4
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

Form

990-BL

Action

Date

O.K. to print
Revised proofs
requested

Information and Initial Excise Tax Return for Black
Lung Benefit Trusts and Certain Related Persons

(Rev. June 2005)
Department of the Treasury
Internal Revenue Service

Signature

OMB No. 1545-0049

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

For calendar year

, or fiscal year beginning

,

, and ending

,

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

City or town, state and ZIP code

If address changed, check here
FMV of assets at beginning


of operator’s tax year

Return filed by (check box that applies):

1
2

Revenue

a
b
c

d
3

Expenses

Contributions received
Investment income:
Interest on certain securities of the U.S., state, and local governments
Interest on time or demand deposits in a bank or insured credit union (described in
section 501(c)(21)(D)(ii)(III))
Gross amount received from sale of assets
Less cost or other basis and sales expenses
Net gain or (loss)
Other income (attach schedule)


Total revenue (add lines 1 through 2d)
Contributions to the Federal Black Lung Disability Trust Fund
Premiums for insurance to cover liabilities described in section 501(c)(21)(A)(i)(I) and
501(c)(21)(A)(i)(IV)
Other payments to or for benefit of eligible coal miners, retired miners, or beneficiaries
Compensation of trustees
Other salaries and wages
Administrative expenses not included on lines 7 and 8 (attach schedule)
Other expenses (attach schedule)
Total expenses (add lines 4 through 10)


Excess of revenue over expenses (subtract line 11 from line 3)

4
5
6
7
8
9
10
11
12

Balance Sheets

Part II

Assets

Trustee (Not open for public inspection)

Analysis of Revenue and Expenses

Part I

Liabilities
and
Net Assets

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

Cash
Savings and interest-bearing accounts
Investments in approved securities
Office supplies and equipment
Other assets (attach schedule)
Total assets (add lines 13 through 17)

19
20

Liabilities (see instructions)
Net assets

21

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

Please
Sign
Here
Paid
Preparer’s
Use Only

2a
2b

2c
2d
3
4
5
6
7
8
9
10
11
12

Beginning of year

13
14
15
16
17
18

The books are in care of
Located at

1

End of year

13
14
15
16
17
18
19
20
21

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
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.

Signature of person filing return

Preparer’s
signature

Firm’s name (or
yours, if self-employed)
and address

Date

Title
Date

For Privacy Act and Paperwork Reduction Act Notice, see page 4 of the separate instructions.

ZIP code
Cat. No. 10315Y

Form

990-BL

(Rev. 6-2005)

1
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-BL, PAGE 2 of 4
PRINTS: HEAD TO FOOT
MARGINS: TOP 13mm (1⁄2 ", CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 559mm (22"), FOLDED TO 216mm (81⁄2 ") x 279mm (11")
PERFORATE: HORIZONTALLY ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-BL (Rev. 6-2005)

Part III

Page

Questionnaire

2

Yes No

22

Have you made any changes not previously reported to the Internal Revenue Service in your governing instrument,
or other similar instrument?
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):
(1) Engage in the sale, exchange, or leasing of property with a disqualified person?
(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 of, a disqualified person?
(5) Transfer any income or assets to, or for use by or for the benefit of, a disqualified person?
b 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?
c If the answer is “No” to question 23b, complete Schedule A (Form 990-BL), Part I, Section A.
24

25

26

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?
If the answer is “Yes,” complete Schedule A, Form 990-BL, Part I, Section B.
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).
Officers, directors, trustees and their compensation, if any, for the tax year:
(a)
Name and Address

(b)
Title and time
devoted to position

(c)
Contributions
to employee
benefit plans

(d)
Expense
account, other
allowances

Total

Part IV
1

Statement With Respect to Contributors, etc. — (Not open for public inspection)

Persons who contributed $5,000 or more in the taxable year (if more space is needed, attach schedule):
Name

2

(e)
Compensation
(If not paid,
enter zero.)

Address

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?
Form

990-BL

Yes No
(Rev. 6-2005)

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 990-BL, PAGE 3 of 4 (PAGE 4 IS BLANK)
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PRINTS: HEAD TO FOOT
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 559mm (22"), FOLD TO: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: HORIZONTALLY ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page

Form 990-BL (Rev. 6-2005)

3

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
, or fiscal year beginning
Name of trust/person filing return (see instructions)

,

, and ending

Name of related section 501(c)(21) trust (if applicable)
Return filed by (see instructions, check box that applies):

Part I

,
Employer identification number or
social security number of filer (see
instructions)

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

(f) Amount involved in act

(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))

Total (add lines 1 through 4,
䊳
columns (g) and (h))
SECTION B—Taxable Expenditures and Tax Computation (Section 4952)
(a) Item
number

(b) Amount

(c) Date paid
or incurred

(e) Description of expenditure and
purposes for which made

(d) Name and address of recipient

1
2
3
4
(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))

Part II

(h) Tax imposed on
trustee (if applicable)
(21⁄2% of column (b))

䊳

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

Total tax due (add lines 1 through 4)

䊳

5
Form

990-BL

(Rev. 6-2005)