Form 990-BL
(Rev. December 2013)
Department of the Treasury
Internal Revenue Service
Information and Initial Excise Tax Return for Black
Lung Benefit Trusts and Certain Related Persons
Under section 501(c)(21) of the Internal Revenue Code.
Information about Form 990-BL and its instructions is available at www.irs.gov/form990bl.
OMB No. 1545-0049
For calendar year , or fiscal year beginning , , and ending ,
Name of trust
Employer identification number (EIN) of trust
Name of other person filing return
Social security number (SSN) or EIN of other filer
Number, street, and room or suite no. (If a P.O. box, see instructions.)
If application pending, check here . .
If address changed, check here . . .
City or town, state or province, country, ZIP or foreign postal code
FMV of assets at beginning
of operator’s tax year .
Return filed by (check box that applies): Trust (Open for public inspection—other than Part IV) Trustee (Not open for public inspection)
Disqualified person (Not open for public inspection)
Part I
Analysis of Revenue and Expenses
Revenue
1 Contributions received . . . . . . . . . . . . . . . . . . . . . . . 1
2 Investment income:
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)(D)(ii)(III)) . . . . . . . . . . . . . . . . . . . . . .
2b
c Gross amount received from sale of assets . . . . . . . .
Less cost or other basis and sales expenses . . . . . . . .
Net gain or (loss) . . . . . . . . . . . . . . . . . . . . . . . . . 2c
d Other income (attach schedule) . . . . . . . . . . . . . . . . . . . . 2d
3 Total revenue (add lines 1 through 2d) . . . . . . . . . . . . . . . .
3
Expenses
4 Contributions to the Federal Black Lung Disability Trust Fund . . . . . . . . . . 4
5
Premiums for insurance to cover liabilities described in section 501(c)(21)(A)(i)(I) and
501(c)(21)(A)(i)(IV) . . . . . . . . . . . . . . . . . . . . . . . . .
5
6 Other payments to or for benefit of eligible coal miners, retired miners, or beneficiaries . . 6
7 Compensation of trustees . . . . . . . . . . . . . . . . . . . . . . 7
8 Other salaries and wages . . . . . . . . . . . . . . . . . . . . . . 8
9 Administrative expenses not included on lines 7 and 8 (attach schedule) . . . . . . . 9
10 Other expenses (attach schedule) . . . . . . . . . . . . . . . . . . . 10
11 Total expenses (add lines 4 through 10) . . . . . . . . . . . . . . . . .
11
12 Excess of revenue over expenses (subtract line 11 from line 3) . . . . . . . .
12
Part II
Balance Sheets
Beginning of year End of year
Assets
13 Cash . . . . . . . . . . . . . . . . . . . . . 13
14 Savings and interest-bearing accounts . . . . . . . . . . 14
15 Investments in approved securities . . . . . . . . . . . 15
16 Office supplies and equipment . . . . . . . . . . . . 16
17 Other assets (attach schedule) . . . . . . . . . . . . 17
18 Total assets (add lines 13 through 17) . . . . . . . . . .
18
Liabilities
and
Net Assets
19 Liabilities (see instructions) . . . . . . . . . . . . . . 19
20 Net assets . . . . . . . . . . . . . . . . . . . 20
21 Total liabilities and net assets (add lines 19 and 20) . . . . . .
21
The books are in care of
Telephone number
Located at
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 officer or trustee) is based on all information of which preparer has any knowledge.
Sign
Here
Signature of officer or trustee
Date
Type or print name and title
Paid
Preparer
Use Only
Print/Type preparer’s name Preparer's signature Date
Check if
self-employed
PTIN
Firm’s name
Firm's EIN
Firm's address
Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .
Yes No
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 10315Y
Form 990-BL (Rev. 12-2013)
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Form 990-BL (Rev. 12-2013)
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Part III
Questionnaire
Yes No
22
Have you made any changes not previously reported to the Internal Revenue Service in your governing instrument,
or other similar instrument? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23 If “Yes,” attach a conformed copy of the changes.
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
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.
25
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).
26 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
(e)
Compensation
(If not paid,
enter zero.)
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part IV
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? . . . . . . . . . . . . . . . . . .
Yes No
Form 990-BL (Rev. 12-2013)
Form 990-BL (Rev. 12-2013)
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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 , , and ending ,
Name of trust/person filing return (see instructions)
Name of related section 501(c)(21) trust (if applicable)
EIN or SSN of filer (see instructions)
Return filed by (see instructions, check box that applies):
Trust Trustee
Disqualified person
Part I 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 (e) Names of trustees liable for tax
(f) Amount involved in act
(g) Initial tax on self-dealing disqualified person
(10% of column (f))
(h) Tax on trustee (if applicable)
(2½% of column (f))
Total (add lines 1 through 4,
columns (g) and (h)) . . . . . .
SECTION B—Taxable Expenditures and Tax Computation (Section 4952)
(a) Item
number
(b) Amount
(c) Date paid
or incurred
(d) Name and address of recipient
(e) Description of expenditure and
purposes for which made
1
2
3
4
(f) Names of trustees liable for tax
(g) Tax imposed on trust
(10% of column (b))
(h) Tax imposed on
trustee (if applicable)
(2½% of column (b))
Total (Add lines 1 through 4, columns (g) and (h)) . . . . . . . . . . .
Part II 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) . . . . . . . . . . . . . . . . . . .
5
Form 990-BL (Rev. 12-2013)
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