Form 6069 - Return Of Excise Tax On Excess Contributions To Black Lung Benefit Trust Under Section 4953 And Computation Of Section 192 Deduction

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6069

Return of Excise Tax on Excess Contributions to

OMB No. 1545-0049

Form

Black Lung Benefit Trust Under Section 4953 and

(Rev. February 2012)

NOT Open for

Computation of Section 192 Deduction

Department of the Treasury

Public Inspection

Internal Revenue Service

For calendar year

, or fiscal year beginning

, and ending

Employer identification number

Operator’s name

Number, street, and room or suite no. (or P. O. box number)

If address changed, check here

▶

City or town, state and ZIP code

Name of related section 501(c)(21) trust

Employer identification number of related trust

Schedule A

Worksheet for Computing the Section 192 Deduction by Coal Mine Operators (See instructions)

Enter the amount necessary to fund (with level funding) the remaining unfunded liability for claims

filed or expected to be filed by, or on behalf of, past or present employees of the operator based on:

a The average remaining working life of miners currently employed

b 10 tax years .

c Any other funding period prescribed or approved by the Secretary

of the Treasury .

d Enter the smaller of line 1a or 1b .

e Enter the larger of line 1c or 1d .

2 a Enter the amount necessary to carry out section 501(c)(21)(A)

purposes for the tax year .

b Enter the fair market value of the trust’s assets (see instructions)

c Subtract line 2b from line 2a (if less than zero, enter -0-)

Maximum allowable deduction (enter the larger of line 1e or line 2c)

▶

Schedule B

Computation of Section 4953 Tax by the Person Making Excess Contributions Under Section 192

to a Section 501(c)(21) Trust (See instructions)

1 a Contributions made to section 501(c)(21) trust for operator’s tax year

b Operator’s maximum allowable deduction under section 192 for tax

year (enter amount from Schedule A, line 3)

c Subtract line 1b from line 1a (if less than zero, enter -0-)

Excess contributions carried over from the preceding tax year

Total (add lines 1c and 2)

Amount that current year’s contributions are less than the

maximum amount deductible (subtract line 1a from line 1b) (if less

than zero, enter -0-)

Amount of previous year’s excess contributions that were returned

to the contributor during the current tax year .

Total (add lines 4 and 5) .

Excess contributions for current year (subtract line 6 from line 3)(if less than zero, enter -0-) .

Tax due (enter 5% of line 7). Pay in full with return. .

▶

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

Please

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.

Sign

Here

Title

Signature of person filing return

Date

Print/Type preparer’s name

Preparer's signature

Date

PTIN

Paid

Check

self-employed