Form 990-BL-- Information and Initial Excise Tax Return for Black Lung Benefit Trusts and Certain Related Persons

Instructions for
Form 990-BL

Department of the Treasury
Internal Revenue Service

(Rev. December 2013)

Information and Initial Excise Tax Return for Black Lung Benefit Trusts and Certain
Related Persons
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form 990-BL and its instructions, such as legislation after they
were published, go to www.irs.gov/form990bl.

General Instructions
Purpose of Form

Form 990-BL is generally used by black lung benefit trusts to meet
the reporting requirements of section 6033. If initial taxes are imposed on
the trust or certain related parties, trusts must also file Schedule A (Form
990-BL), Initial Excise Taxes on Black Lung Benefit Trusts and Certain
Related Persons.

Who Must File

The trustee must file Form 990-BL for a trust exempt from tax under
section 501(a) and described in section 501(c)(21), unless the trust
normally has gross receipts in each tax year of not more than $50,000.
A trust that normally has gross receipts of $50,000 or less must file an
annual electronic notice. See www.irs.gov/charities and click on “Annual
Electronic Filing Requirement for Small Exempt Organizations—Form
990-N (e-Postcard)” for more information.
The initial excise taxes imposed on black lung benefit trusts, trustees,
and disqualified persons under sections 4951 and 4952 are reported on
Schedule A (Form 990-BL).
A black lung benefit trust required to file an annual information return
and liable for tax under section 4952 should complete Form 990-BL and
attach a completed Schedule A (Form 990-BL). A trust liable for section
4952 tax but not otherwise required to file Form 990-BL should complete
the identification and signature area of Form 990-BL and attach a
completed Schedule A (Form 990-BL).
A trustee or disqualified person liable for section 4951 or 4952 tax
should complete the heading (omitting the check boxes for application
pending, address change, and fair market value of assets) and signature
area of Form 990-BL and attach a completed Schedule A (Form
990-BL). A trustee liable for sections 4951 and 4952 taxes reports both
taxes on one return.
If no tax is due under section 4951 or 4952, do not file Schedule A
(Form 990-BL).
Your Area Director will tell you what procedures to follow if the trust or
any related persons incur any liability for additional taxes and penalties
based on sections 4951 and 4952.
Form 990-BL will not be automatically mailed to the persons required
to file it but may be requested from the Forms Distribution Center for your
state by calling 1-800-TAX-FORM (1-800-829-3676).
An organization claiming an exempt status under section 501(c)(21)
prior to the establishment of exempt status should file this return if its
application for recognition of exemption is pending (including appeal of a
proposed adverse decision).
The return must be on the basis of the established annual accounting
period of the organization. If the organization has no established
Jul 03, 2013

Accounting Methods

Gross income, receipts, and disbursements must be figured by the
method of accounting regularly used by the organization in maintaining
its books and records, unless otherwise specified in the instructions.

When and Where To File

The Black Lung Benefits Revenue Act of 1977 (the Act) amended the
Internal Revenue Code to impose excise tax on the sale of coal by the
producer and established a trust fund (funded by the coal tax and certain
other revenues) to be available for expenses of providing medical
benefits where not paid by the appropriate mine operator.

Accounting Period

accounting period, the return should be on the basis of the calendar
year.

This return, including Schedule A (Form 990-BL) if tax is due, must be
filed on or before the 15th day of the 5th month following the close of the
filer's tax year. If the regular due date falls on a Saturday, Sunday, or
legal holiday, file on the next business day. File it at the following
address:
Internal Revenue Service
201 W. River Center Blvd.
Stop 31, TE/GE
Covington, KY 41011
You may request an extension of time to file Form 990-BL by filing
Form 8868, Application for Extension of Time To File an Exempt
Organization Return.
Rounding off to whole dollars. You may show the money items on the
return and accompanying schedules as whole-dollar amounts. To do so,
drop amounts less than 50 cents and increase any amounts from 50 to
99 cents to the next dollar. For example, $1.39 becomes $1 and $2.50
becomes $3.
If you have to add two or more amounts to figure the amount to enter
on a line, include cents when adding the amounts and round off only the
total.
Attachments. If you need more space, attach separate sheets showing
the same information in the same order as on the printed forms. Show
the totals on the printed forms.
Enter the trust's employer identification number (EIN) (or the
disqualified person's social security number (SSN)) on each sheet. Also,
use sheets that are the same size as the forms and indicate clearly the
line of the printed form to which the information relates.

Penalties

If an organization fails to file timely, correctly, or completely, it will have to
pay $20 for each day ($100 a day if it is a large organization) during
which such failure continues, unless it can be shown that the failure was
due to reasonable cause. The maximum penalty with respect to any one
return is the smaller of $10,000 ($50,000 for a large organization) or 5%
of the gross receipts of the organization for the year.
The IRS may make written demand that the delinquent return be filed
or the information furnished within a reasonable time after mailing of
notice of the demand. The person failing to comply with the demand on
or before the date specified in the demand will have to pay $10 for each
day the failure continues, unless there is reasonable cause. The
maximum penalty imposed on all persons for failures with respect to any
one return shall not exceed $5,000. If more than one person is liable for
any failures, all such persons are jointly and severally liable with respect
to such failures. See section 6652(c).
To avoid having to explain an incomplete return, if a part or line item
does not apply, enter “N/A” (not applicable) or “-0-” if an amount is zero.
There are penalties for willful failure to file and for filing fraudulent
returns and statements. (See sections 7203, 7206, and 7207.)

Cat. No. 10316J

response to the application. An organization that submitted its exemption
application on or before July 15, 1987, must also comply with this
requirement if it had a copy of its application on July 15, 1987. As in the
case of annual returns, the copy of the application and related
documents must be made available for inspection during regular
business hours at the organization's principal office and at each of its
regional or district offices having at least three employees.

Large organization. A large organization is one that has gross receipts
greater than $1 million for the tax year.

Public Inspection of Completed
990-BL Returns and Approved
Exemption Applications

Penalties for failure to comply with public inspection requirements. If a person does not comply with the requirement to permit
public inspection of annual returns, there is a penalty of $20 for each day
during which such failure continues, unless there is reasonable cause.
The maximum penalty imposed on all persons for failures that apply to
any one return is $10,000.

Through the IRS. Generally, the information reported on or with Form
990-BL, including most attachments, is available for public inspection
(section 6104(b)). This applies both to information required by the form
and to information furnished voluntarily. Approved applications for
exemption from federal income tax are also available for public
inspection.
Exception. Part IV of Form 990-BL, Statement With Respect to
Contributors, etc., and Schedule A (Form 990-BL) are not open to public
inspection.

If a person does not comply with the public inspection of applications
requirement, there is a penalty of $20 a day for each day during which
such failure continues, unless there is reasonable cause. There is no
maximum penalty limitation (see section 6652(c)).
Any person who willfully does not comply with the public inspection
requirements for the annual return or application is subject to an
additional penalty of $5,000 for each return or application (see section
6685).

The public inspection rules do not apply to Form 990-BL and the
attached Schedule A (Form 990-BL) filed by a trustee or disqualified
person to report initial taxes on self-dealing or taxable expenditures. The
public inspection rules also do not apply to the trustee or disqualified
person's SSN or EIN.

If more than one person is liable for any penalty, all such persons
shall be jointly and severally liable for each failure.

Use Form 4506-A, Request for Public Inspection or Copy of Exempt
or Political Organization IRS Form, to request a copy or to inspect an
exempt organization return through IRS. There is a fee for photocopying,
but not for inspection at an IRS office.

Specific Instructions
Identification Area

Through the organization—Annual return. An organization must,
during the 3-year period beginning with the due date (including
extensions) of the Form 990-BL (or, if later, the date it is actually filed),
make its return available for public inspection. It must also provide
copies of either all items that are available for public inspection or
specifically identified items, if so requested. All parts of the return and all
required schedules and attachments must be made available except
Part IV of Form 990-BL and Schedule A (Form 990-BL) as discussed
above.

Period covered by the return. Enter the calendar year or fiscal year
that corresponds to the accounting period being reported.
Name and address. Enter the name and address of the trust.
If the return and a Schedule A (Form 990-BL) are filed by a trustee or
disqualified person liable for tax under section 4951 or 4952, then enter
that person's name and address below the name of the trust.

Inspection and requests for copies must be permitted during regular
business hours at the organization's principal office and at each of its
regional or district offices. This provision applies to any organization that
files Form 990-BL, regardless of the size of the organization and whether
or not it has any paid employees. Also, copies must be provided the
same business day they are requested unless unusual circumstances
exist. In the case of unusual circumstances, the copies must be provided
by the next business day after the day the unusual circumstances cease
to exist, but in no event may the delay exceed five business days. See
Regulations section 301.6104(d)-1 for what constitutes unusual
circumstances and the definition of regional and district offices.

Include the suite, room, or other unit number after the street address.
If the Post Office does not deliver mail to the street address and the filer
has a P.O. box, show the box number instead of the street address.
Foreign address. Enter the information in the following order: city or
town, state or province, and country. Follow the country's practice for
entering the postal code, if any. Do not abbreviate the country name.
“Return filed by.” Check only the box that applies to you.
1. Check the “Trust” box when the return is filed by a black lung
benefit trust as an information return, or tax return, or both.
2. Check the “Trustee” box when the return is filed by a trustee
because of liability for taxes under section 4951 or 4952, or both.

When a request for copies is made in writing, the copies must
generally be sent within 30 days of the date the request was received.

3. Check the “Disqualified person” box when the return is filed by a
disqualified person who is liable for section 4951 tax only.

Note. A black lung benefit trust does not have to comply with individual
requests for copies if it makes this information widely available. This can
be done by posting the application for tax exemption and/or an annual
information return on a readily accessible World Wide Website.
However, an organization that makes its information available this way
must advise requesters how the material may be accessed. See
Regulations section 301.6104(d)-2 for specific instructions.
Fee for copies. An organization may charge a reasonable fee for
providing copies.

Taxpayer identification number. Enter the EIN of the black lung
benefit trust. If the return is being filed by a trustee or disqualified person,
also enter that person's SSN or EIN.
Each trust should have only one employer identification number. If
the trust has more than one number and has not been advised which
one to use, you should notify the:

Before the organization provides the documents, it may require that
the individual requesting copies of the documents pay the fee. If the
organization has provided an individual making a request with notice of
the fee, and the individual does not pay the fee within 30 days, or if the
individual pays the fee by check and the check does not clear upon
deposit, the organization may disregard the request.
Additional information. See Regulations sections 301.6104(d)-1
through 301.6104(d)-3 for additional information on reasonable fees for
providing copies, not filling requests for copies when material is widely
available, and other related information.

Internal Revenue Service Center
Attention: Entity Control, Stop 6273
Ogden, UT 84201-0027
Inform them what numbers the trust has, the name and address to
which each number was assigned, and the address of its principal office.
The IRS will then advise you which number to use.
Application pending, address change, and FMV of assets. Fill in
these blocks only when a return must be filed for a trust. Enter the fair
market value (FMV) of the trust's assets at the beginning of the
operator's tax year within which the trust's tax year begins.

Exemption application. Any section 501(c)(21) organization that
submitted an application for recognition of exemption to the IRS after
July 15, 1987, must make available for public inspection a copy of its
application (together with a copy of any papers submitted in support of
its application) and any letter or other document issued by the IRS in

Signature. The return must be signed by the authorized trustee or
trustees and also by any person, firm, or corporation who signed the
return. If the return is prepared by a firm or corporation, it should be
signed in the name of the firm or corporation.
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Paid preparer. Generally, anyone who is paid to prepare the return
must sign the return and fill in the other blanks in the Paid Preparer Use
Only area. An employee of the filing organization is not a paid preparer.

Line 9. Enter the administrative expenses (including legal, accounting,
actuarial, and trustee expenses) for the year other than salaries and
wages paid to trustees and other employees.

The paid preparer must:
Sign the return in the space provided for the preparer's signature,
Enter the preparer information, and
Give a copy of the return to the organization.

Line 10. Attach a schedule, listing by type and amount, all allowable
deductions that are not deductible elsewhere on Form 990-BL. Enter the
total of these deductions on line 10. See Regulations section
1.501(c)(21)-1 for additional information.

Part II—Balance Sheets

The paid preparer must also enter the preparer's identifying number
and the firm's EIN. The preparer's identifying number is the preparer's
taxpayer identification number (PTIN).

Complete the balance sheets on the basis of the accounting method
regularly used by the trust in keeping its books and records.

Because the Form 990-BL is a publicly disclosable document,
any information entered in this block will be publicly disclosed
CAUTION
(see Public Inspection of Completed 990-BL Returns and
Approved Exemption Applications). Any paid preparer whose identifying
number must be listed on Form 990-BL can apply for and obtain a PTIN
using Form W-12, IRS Paid Preparer Tax Identification Number (PTIN)
Application and Renewal. For more information about applying for a
PTIN online, visit the IRS website at www.irs.gov/ptin.

Line 19. Enter only liabilities of the trust as of the first and last days of
the tax year of the trust. Include payments for approved black lung
claims that are due but not paid, accrued trustee fees, etc. Do not
include amounts for black lung claims being contested, the present value
of payments for approved claims, or the estimated liability for future
claims.

!

Line 21. Enter the total of lines 19 and 20. That figure must equal the
figure for total assets reported on line 18 for both the beginning and end
of year.

Paid preparer authorization. On the last line of the Signature Block,
check “Yes,” if the IRS can contact the paid preparer who signed the
return to discuss the return. This authorization applies only to the
individual whose signature appears in the Paid Preparer Use Only
section of Form 990-BL. It does not apply to the firm, if any, shown in that
section. By checking “Yes,” to this box, the organization is authorizing
the IRS to contact the paid preparer to answer any questions that arise
during the processing of the return.

Part III—Questionnaire
General Instructions
The Black Lung Benefits Revenue Act of 1977 imposes excise taxes and
penalties on acts of self-dealing between trusts and disqualified persons,
and on taxable expenditures made by the trusts. These taxes and
penalties apply to the trust (section 4952), trustees (sections 4951 and
4952), and self-dealers (section 4951). The purpose of the questions is
to determine whether there is any initial tax due under either of these two
sections.

The organization is also authorizing the paid preparer to:
Give the IRS any information missing from the return;
Call the IRS for information about processing the return; and
Respond to certain IRS notices about math errors, offsets, and return
preparation.
The organization is not authorizing the paid preparer to bind the
organization to anything or otherwise represent the organization before
the IRS.

Definitions
Self-dealing (Section 4951)

The authorization will automatically end no later than the due date
(excluding extensions) for filing the Form 990-BL. If the organization
wants to expand the paid preparer’s authorization or revoke it before it
ends, see Pub. 947, Practice Before the IRS and Power of Attorney.

Self-dealing. For purposes of section 4951, the term “self-dealing”
means any direct or indirect:
Sale, exchange, or leasing of real or personal property between a trust
described in section 501(c)(21) and a disqualified person;
Lending of money or other extension of credit between such a trust
and a disqualified person;
Furnishing of goods, services, or facilities between such a trust and a
disqualified person;
Payment of compensation (or payment or reimbursement of
expenses) by such a trust to a disqualified person; and
Transfers to, or use by or for the benefit of, a disqualified person of the
income or assets of such a trust.

Check “No,” if the IRS should contact the organization or its trustee
rather than the paid preparer.

Part I—Analysis of Revenue and
Expenses
Line 1. Enter the total contributions received under section 192 from the
coal mine operator who established the trust.
Contributions to the trust must be in cash or property of the type in
which the trust is permitted to invest (i.e., public debt securities of the
United States, obligations of a state or local government that are not in
default as to principal or interest, or time and demand deposits in a bank
or insured credit union as described in section 501(c)(21)(D)(ii)).

Special rules. For purposes of section 4951:
The transfer of personal property by a disqualified person to such a
trust is treated as a sale or exchange if the property is subject to a
mortgage or similar lien;
If a bank or an insured credit union is a trustee of the trust or otherwise
is a “disqualified person” with respect to the trust, any amount invested in
checking accounts, savings accounts, certificates of deposit, or other
time or demand deposits in that bank or credit union constitutes a
lending of money;
The furnishing of goods, services, or facilities by a disqualified person
to such a trust is not an act of self-dealing if the furnishing is without
charge and if the goods, services, or facilities so furnished are used
exclusively for the purposes specified in section 501(c)(21)(A); and
The payment of compensation (and the payment or reimbursement of
expenses) by such a trust to a disqualified person for personal services
that are reasonable and necessary to carry out the exempt purpose of
the trust is not an act of self-dealing if the compensation (or payment or
reimbursement) is not excessive. See Regulations section 53.4951-1 for
additional information.

Line 2. Enter the amounts received during the year from the sources
listed in 2a, b, c, and d.
Line 4. Enter the amounts contributed by the trust to the Federal Black
Lung Disability Trust Fund as provided for by section 3(b)(3) of Public
Law 95-227.
Line 5. Enter the amounts paid for insurance exclusively covering
liabilities under sections 501(c)(21)(A)(i)(I), and 501(c)(21)(A)(i)(IV). For
details, see Regulations section 1.501(c)(21)-1(d).
Line 6. Enter the amounts paid to or for the benefit of miners or their
beneficiaries other than amounts included in lines 4 or 5. Such payments
could include direct payment of medical bills, etc., authorized by the Act
and accident and health benefits for retired miners and their spouses
and dependents.

Taxable period. The term “taxable period” means, with respect to any
act of self-dealing, the period beginning with the date on which the act of
self-dealing occurs and ending on the earliest of:

Line 7. Enter the total amount of compensation for the year of all
trustees. See Part III, line 26.
Line 8. Enter the total of the salaries and wages of all employees other
than those included in line 7.

1. The date of mailing of a notice of deficiency under section 6212,
with respect to the tax imposed by section 4951(a)(1),
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2. When full recovery is not possible, by contributions by the person
or persons whose liabilities for black lung benefit claims (as defined in
section 192(e)) are to be paid out of the trust.

2. The date on which the tax imposed by section 4951(a)(1) is
assessed, or
3. The date on which correction of the act of self-dealing is
completed.

Taxable period. The term “taxable period” means, with respect to any
taxable expenditure, the period beginning with the date on which the
taxable expenditure occurs and ending on the earlier of:

Amount involved. The term “amount involved” means, for any act of
self-dealing, the greater of the amount of money and the fair market
value (FMV) of the other property given or the amount of money and the
FMV of the other property received. However, in the case of services
described in section 4951(d)(2)(C), the amount involved is only the
excess compensation. For purposes of the preceding sentence, the
FMV:

1. The date of mailing a notice of deficiency under section 6212
with respect to the tax imposed by section 4952(a)(1), or
2. The date on which the tax imposed by section 4952(a)(1) is
assessed.

Specific Instructions

1. For the initial taxes imposed by section 4951(a), is determined as
of the date on which the act of self-dealing occurs; and

Line 22. A “conformed” copy is one that agrees with the original
document, and all amendments to it. If the copies are not signed, they
must be accompanied by a written declaration signed by an officer
authorized to sign for the organization certifying that they are complete
and accurate copies of the original documents.

2. For additional taxes imposed by section 4951(b), is the highest
FMV during the taxable period.
Correction. The terms “correction” and “correct” mean, for any act of
self-dealing, undoing the transaction to the extent possible, but in any
case placing the trust in a financial position not worse than that in which
it would be if the disqualified person were dealing under the highest
fiduciary standards.

Chemically or photographically reproduced copies of articles of
incorporation showing the certification of an appropriate State official
need not be accompanied by such a declaration. See Rev. Proc. 68-14,
1968-1 C.B. 768, for additional information.

Disqualified person. The term “disqualified person” means, for a trust
described in section 501(c)(21), a person who is:
1.

A contributor to the trust;

2.

A trustee of the trust;

3.

An owner of more than 10% of:

a.

The total combined voting power of a corporation,

b.

The profits interest of a partnership, or

Line 23. If you answered “Yes,” to 23a(1), (2), (3), (4), or (5) and “No,”
to 23b, notify each self-dealer and trustee who may be liable for initial
taxes under section 4951 of the requirement to file a return for each year
(or part of a year) and pay the applicable tax. The trust must also furnish
the information required by Schedule A (Form 990-BL), Part I, Section A
(other than columns (g) and (h)) on its own return.
For exceptions to the self-dealing rules, see Special Rules and
Payment of Benefits, earlier.

c. The beneficial interest of a trust or unincorporated enterprise,
which is a contributor to the trust;

Line 24. If you answered “Yes,” complete Part I, Section B (other than
column (h)) and Part II of Schedule A (Form 990-BL). The trust must also
notify any trustees who may be liable for initial taxes under section 4952
of the requirement to file Form 990-BL, Schedule A (Form 990-BL), and
to pay the tax.

4. An officer, director, or employee of a person who is a contributor
to the trust;
5. The spouse, ancestor, lineal descendant, or spouse of a lineal
descendant of an individual described in 1, 2, 3, or 4;

Line 25. If you answered “No,” or if there were multiple acts or
transactions giving rise to Chapter 42 taxes and all of them were not
corrected, attach an explanation of each uncorrected act including the
names of all parties to the act, the date of the act, the amount involved,
why the act has not been corrected, and the date you expect correction
to be made.

6. A corporation of which persons described in 1, 2, 3, 4, or 5 own
more than 35% of the total combined voting power;
7. A partnership in which persons described in 1, 2, 3, 4, or 5 own
more than 35% of the profits interest; or
8. A trust or estate in which persons described in 1, 2, 3, 4, or 5
hold more than 35% of the beneficial interest.

Line 26. List each of the organization's officers, directors, trustees, and
other persons having responsibilities or powers similar to those of
officers, directors, or trustees. List all of these persons even if they did
not receive any compensation from the organization. Show all forms of
compensation received by each listed officer, etc. Enter “-0-” in columns
(c), (d), and (e) if none was paid.

For purposes of items 3a and 6 above, indirect stockholdings are
taken into account if they would be taken into account under section
267(c), except that, for purposes of this paragraph, section 267(c)(4) is
treated as providing that the members of the family of an individual are
only those individuals described in item 5. For purposes of items 3b and
c, 7, and 8, the ownership of profits or beneficial interests is determined
by the rules for constructive ownership of stock provided in section
267(c) (other than paragraph (3)), except that section 267(c)(4) is
treated as providing that the members of the family of an individual are
only those individuals described in item 5.

Note. If you pay any other person, such as a management service
company, for the services provided by any of your officers, directors,
trustees, or key employees, report the compensation and other items on
line 26 as if you had paid the officer, etc. directly.
Column (b). In column (b), a numerical estimate of average hours per
week devoted to the position is required for a complete answer. Phrases
such as “as needed” or “as required” are unacceptable.

Payment of benefits. For purposes of section 4951, a payment out of
assets or income of a trust described in section 501(c)(21) for the
purposes described in sections 501(c)(21)(A)(i)(I) and
501(c)(21)(A)(i)(IV) is not considered an act of self-dealing.

Column (c). Include all forms of deferred compensation (whether or not
funded and whether or not the deferred compensation plan is a qualified
plan under section 401(a)) and payments to welfare benefit plans on
behalf of the officers, etc.

Taxable Expenditures (Section 4952)

Column (d). Enter expense allowances or reimbursements that the
recipients must report as income on their separate income tax returns.
Examples include amounts for which the recipient did not account to the
organization or allowances that were more than the payee spent on
serving the organization. Include payments made under indemnification
arrangements, the value of the personal use of housing, automobiles, or
other assets owned or leased by the organization (or provided for the
organization's use without charge), as well as any other taxable and
nontaxable fringe benefits. Get Pub. 525, Taxable and Nontaxable
Income, for details.

Taxable expenditure. For purposes of section 4952, the term “taxable
expenditure” means any amount paid or incurred by a trust described in
section 501(c)(21) other than for a purpose specified in that section.
Correction. The terms “correction” and “correct” mean, with respect to
any taxable expenditure, placing the trust in a financial position not
worse than that in which it would have been if the taxable expenditure
had not been made:
1. By recovering all or part of the expenditure to the extent recovery
is possible, and

Column (e). Enter salary, fees, bonuses, and severance payments
received by each person listed.
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information required by columns (b) through (g) of Section A, Part I.
Enter “N/A” in column (h). Enter only the “prorated” portion of column (g)
on line 1 of Part II.

Black lung benefit trusts that pay salaries, wages, or other
compensation to officers or other employees are generally liable for filing
Form 941, Employer's Quarterly Federal Tax Return, and Form 940,
Employer's Annual Federal Unemployment (FUTA) Tax Return, to report
social security, withholding, and federal unemployment taxes.

When filer is a trustee, Sections A and B. A trustee liable for initial
taxes under sections 4951 and 4952 completes this schedule by
entering the required information in columns (b) through (h) (other than
(g)) of Section A and/or Section B, Part I. For Section A, enter the
“prorated” portion of column (h) on line 2 of Part II. For Section B, enter
the “prorated” portion of column (h) on line 4 of Part II.

Part IV—Statement With Respect to
Contributors, etc.
Note. This part is not open for public inspection.

Part I—Initial Taxes on Self-dealing and Taxable
Expenditures

Line 1. List the names and addresses of all persons whose
contributions during the tax year totaled $5,000 or more.

Disqualified persons and trustees who participate in acts of self-dealing
with a section 501(c)(21) trust and who have tax years different from the
trust should use their own tax years to figure the initial tax and file the
return.

In determining whether a person has contributed $5,000 or more,
include only contributions of $1,000 or more from such person. Separate
and independent contributions need not be included if less than $1,000.
If a contribution is in the form of property and the fair market value is
readily ascertainable, the description and fair market value must be
submitted. If the fair market value of the property is not readily
ascertainable, you may submit an estimated value.

Initial Section 4951 taxes on self-dealer. An initial tax of 10% of the
amount involved is imposed for each act of self-dealing between a
disqualified person and a section 501(c)(21) trust, for each year (or part
of a year) in the taxable period. The tax is paid by any disqualified
person (other than a trustee acting only as such) who participated in the
act of self-dealing.

The term “person” includes individuals, fiduciaries, partnerships,
corporations, associations, trusts, and exempt organizations.
Line 2. If the trust receives contributions that are more than what the
contributor can deduct under section 192, the person making the excess
contributions may be required to file Form 6069, Return of Excise Tax on
Excess Contributions to Black Lung Benefit Trust Under Section 4953
and Computation of Section 192 Deduction, and pay the tax imposed by
section 4953(a).

Initial Section 4951 taxes on trustee. When a tax is imposed on an
act of self-dealing, any trustee who knowingly participated in such an act
must pay a tax of 21 2% of the amount involved in the act of self-dealing
for each year (or part of a year) in the taxable period unless participation
in the act was not willful and was due to reasonable cause.

Instructions for Schedule A (Form
990-BL)

Initial Section 4952 taxes on trust. An initial tax of 10% of the amount
of the expenditure is imposed on each taxable expenditure from the
assets of a section 501(c)(21) trust. The tax is paid by the trustee out of
the assets of the trust.

Initial Excise Taxes on Black Lung Benefit
Trusts and Certain Related Persons
General Instructions

Initial Section 4952 taxes on trustee. When a tax is imposed on the
trust for a taxable expenditure, any trustee who knowingly agreed to the
expenditure must pay a tax of 21 2% of the amount of the taxable
expenditure unless such agreement was not willful and was due to
reasonable cause.

Schedule A (Form 990-BL) is not open for public inspection. If you attach
any exhibits to Schedule A (Form 990-BL), be sure to label them and
write “Not open for public inspection” on them.

Liability for tax. A person's liability for tax as a self-dealer or trustee
under sections 4951 and 4952 is joint and several. Therefore, if more
than one person is liable for tax on an act of self-dealing as a self-dealer
or trustee, they may prorate the tax among themselves. The IRS may
assess a deficiency against one or more self-dealers or trustees liable
for the tax under section 4951 or 4952, regardless of the apportionment
of tax shown on the return, if the amount paid by all those who are liable
for a particular transaction, is less than the total tax due for that
transaction.

Purpose of form. Use Schedule A (Form 990-BL) only to report initial
taxes under section 4951 or 4952. Schedule A (Form 990-BL) must be
attached to a completed Form 990-BL. It cannot be filed separately. If no
taxes are due under section 4951 or 4952, do not file Schedule A (Form
990-BL).

Specific Instructions

Part II—Summary of Taxes

See Who Must File in the “General Instructions” and the “Specific
Instructions” of Form 990-BL for completing the identification area of this
schedule.

Generally, no more than three lines in Part II will be completed on any
return. However, when a trustee is liable for section 4951 initial taxes,
both as a trustee and as a self-dealer, and is also liable for section 4952
initial taxes because of taxable expenditure involvement, enter the
section 4951 taxes on lines 1 and 2 and enter the section 4952 tax on
line 4, with a total of the tax due on line 5. Pay in full with the return.
Make the check or money order payable to the “United States Treasury”.
In all other instances, follow “Specific Instructions” given above.

When filer is a trust. A trust filing this schedule for a year in which
there are initial taxes due under section 4951 or 4952 completes Part I
as follows:
Section A (Section 4951). Enter the information required in columns
(b) through (f). Enter “N/A” in columns (g) and (h).

The payment of section 4951 tax for the tax year will not necessarily
satisfy the entire initial tax liability for an act of self-dealing. A self-dealer
who is liable for tax under section 4951 must file Form 990-BL,
Schedule A (Form 990-BL), and must pay the tax for each year (or part
of a year) in the “taxable period.”

Section B (Section 4952). Enter the information required in columns
(b) through (g). Enter “N/A” in column (h).
When filer is a self-dealer, Section A only. A self-dealer liable for
initial taxes under section 4951 completes this schedule by entering the

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on these forms to carry out the Internal Revenue laws of the United
States. Our legal right to ask for the information on this form is Internal Revenue Code sections 4951 and 4952. You are required to give us the
information. 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. Section 6109
requires you to provide your identifying number on the return. If you do not provide the information we ask for, or provide false or fraudulent information,
you may be subject to penalties. We may disclose this information to the Department of Justice for civil or criminal litigation, and to cities, states and the
District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. We may also disclose this information to other
countries under a tax treaty, to federal and state agencies to enforce federal non-tax criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism. Generally, tax returns and tax return information are confidential, as required by section 6103.

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You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid
OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the
administration of any Internal Revenue law.
The time needed to complete and file this form and related schedules will vary depending on individual circumstances. The estimated average
times are:

Form

Recordkeeping

Learning about the law or the Preparing and sending the form
form
to the IRS

990-BL

16 hr., 30 min.

3 hr., 22 min.

3 hr., 48 min.

Sch. A (Form 990-BL)

7 hr., 10 min.

18 min.

25 min.

Comments and suggestions. We welcome your comments about these instructions and your suggestions for future editions. You can send us
comments from www.irs.gov/formspubs. Click on “More Information” and then on “Comment on Tax Forms and Publications.” Or you can send your
comments to:
Internal Revenue Service
Tax Forms and Publications Division
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
We respond to many letters by telephone. Therefore, it would be helpful if you would include your daytime phone number, including the area code,
in your correspondence.
Although we cannot respond individually to each comment received, we do appreciate your feedback and will consider your comments as we revise
our tax products.
Do not send the form to this address. Instead, see When and Where To File, earlier.

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