Form 990-Bl - Information And Initial Excise Tax Return For Black Lung Benefit Trusts And Certain Related Persons

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990-BL
Information and Initial Excise Tax Return for Black
Form
Lung Benefit Trusts and Certain Related Persons
(Rev. December 2013)
OMB No. 1545-0049
Under section 501(c)(21) of the Internal Revenue Code.
Department of the Treasury
Information about Form 990-BL and its instructions is available at
▶
Internal Revenue Service
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
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▶
If address changed, check here .
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▶
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
1
Contributions received .
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1
2
Investment income:
a Interest on certain securities of the U.S., state, and local governments
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2a
b Interest on time or demand deposits in a bank or insured credit union (described in
section 501(c)(21)(D)(ii)(III)) .
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2b
c Gross amount received from sale of assets
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Less cost or other basis and sales expenses .
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Net gain or (loss) .
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2c
d Other income (attach schedule) .
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2d
3
Total revenue (add lines 1 through 2d) .
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3
▶
4
4
Contributions to the Federal Black Lung Disability Trust Fund .
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Premiums for insurance to cover liabilities described in section 501(c)(21)(A)(i)(I) and
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501(c)(21)(A)(i)(IV) .
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5
6
Other payments to or for benefit of eligible coal miners, retired miners, or beneficiaries .
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6
7
Compensation of trustees .
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7
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Other salaries and wages .
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9
Administrative expenses not included on lines 7 and 8 (attach schedule) .
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9
10
Other expenses (attach schedule)
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10
11
Total expenses (add lines 4 through 10)
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11
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Excess of revenue over expenses (subtract line 11 from line 3) .
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12
▶
Part II
Balance Sheets
Beginning of year
End of year
13
13
Cash .
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14
Savings and interest-bearing accounts .
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Investments in approved securities .
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15
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Office supplies and equipment
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16
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17
Other assets (attach schedule)
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18
18
Total assets (add lines 13 through 17) .
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19
Liabilities (see instructions) .
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19
20
Net assets .
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20
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Total liabilities and net assets (add lines 19 and 20) .
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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
Signature of officer or trustee
Date
Here
Type or print name and title
Print/Type preparer’s name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Use Only
Firm’s name
Firm's EIN
▶
▶
Firm's address
Phone no.
▶
May the IRS discuss this return with the preparer shown above? (see instructions) .
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Yes
No
990-BL
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(Rev. 12-2013)
Cat. No. 10315Y

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