Return of Certain Excise Taxes on Mine Operators, Black Lung                                          OMB No. 1545-0047
Form   (Rev. December 2021)6069 Trusts, and Other Persons Under Sections 4951, 4952, and 4953
                                                                                                                                      NOT Open for 
Department of the Treasury      ▶ Go to www.irs.gov/Form6069 for instructions and the latest information.                           Public Inspection
Internal Revenue Service 
A      For calendar year                   or other tax year beginning                               , and ending 
B    Filer is:
 (1)   Section 501(c)(21) Trust
 (2)   Disqualified person;      Trustee;    Mine operator (see instructions)
C    Name of mine operator, trust, or person subject to tax                              D  EIN or SSN 

  Number, street, and room or suite no. (or P.O. box number)                             E
                                                                                                 Address change
  City or town, state, and ZIP code                                                              Amended return

F    Name of related section 501(c)(21) Trust (if the trust is not the filer)            G  EIN of the related trust 

H    Books and records are in care of:                                                   I  Telephone no.

Part I Tax and Payment
  1    Initial tax on the trust under section 4952(a)(1) (Part III, line 4b)  .  . . . . .    .  . . .   . . .                      1
  2    Tax on mine operator under section 4953 (Part IV, line 8) .       .    .  . . . . .    .  . . .   . . .                      2
  3a   Initial tax on self-dealer under section 4951(a)(1) (Part II, line 3d)  . . . . .      3a
  b    Self-dealer’s ratable share of liability (see instructions)  . .  .    .  . . . .      3b             %
  c    Filing self-dealer’s liability. Multiply line 3a by percentage share reported on line 3b  . . .   . . .                      3c
  4a   Initial tax on trustee under section 4951(a)(2) (Part II, line 3e)  .  .  . . . .      4a
  b    Filing trustee’s ratable share of liability (see instructions)  . .    .  . . . .      4b             %
  c    Filing trustee’s liability. Multiply line 4a by percentage share reported on line 4b . .  . . .   . . .                      4c
  5a   Initial tax on the trustee under section 4952(a)(2) (Part III, line 4c)   . . . .      5a
  b    Filing trustee’s ratable share of liability (see instructions)  . .    .  . . . .      5b             %
  c    Filing trustee’s liability. Multiply line 5a by percentage share reported on line 5b . .  . . .   . . .                      5c
  6    Total tax. Enter the amount from line 1, or the sum of lines 2, 3c, 4c, and 5c .  .    .  . . .   . . .                      6
  7    Total payments, including amount paid with Form 8868 (see instructions) .       . .    .  . . .   . . .                      7
  8    Tax due. If line 6 is larger than line 7, subtract line 7 from line 6 and enter amount owed . .   . . ▶                      8
  9    Overpayment.             If  line  6  is  smaller  than  line  7,  subtract  line  6  from  line  7  and  enter  the  amount 
       overpaid. This is your refund   . . . . . . .        . .       .  .    .  . . . . .    .  . . .   . . ▶                      9
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.           Cat. No. 12145E                            Form 6069 (Rev. 12-2021) 

Form 6069 (Rev. 12-2021)                                                                                                                                  Page  2 
Part II     Initial Taxes on Self-Dealing (Section 4951)
1   Acts of self-dealing
(a) Act         (b) Date                                                            (c) Description of act                                                                              
number               of act                                                         (see instructions)
(1)
(2)
2   Computation of initial tax on self-dealing disqualified person or trustee
                                                                                    (d) Initial tax on self-dealer               (e) Tax on trustee, if applicable      
(a) Act              (b) Self-dealer(s)         (c) Amount involved                 (10% (0.10) of col. (c))                          (2.5% (0.025) of col. (c))            
number                                                                                                 (see instructions)               (see instructions)
(1)
(2)
3   Totals    .      .   .  . .   .     . . . . . .   . .      . . . .
4   Corrective action. Attach a detailed statement to describe corrective action taken or to explain why corrective action has not 
    been taken. See instructions. 
          (b) Has corrective 
(a) Act   action been taken?                                                  (c) FMV of amount recovered
number
            Yes          No
(1)
(2)
Part III    Initial Taxes on Taxable Expenditures and Tax Computation (Section 4952)
1   Taxable expenditures
(a) Item                    (b) Name and address of recipient                       (c) Description of expenditure and purposes for which made
number
(1)

(2)

2   Taxable expenditures by section 501(c)(21) Trust (section 4952(a))
(a) Item    (b) Date paid or incurred             (c) Amount                                                              (d) Trustees
number
(1)
(2)
3   Computation of initial tax (sections 4952(a)(1) and (2))
    (a) Item                  (b) Tax imposed on section 501(c)(21) Trust                                        (c) Tax imposed on Trustee                                
    number                              (10% (0.10) of line 2, col. (c))                                         (2.5% (0.025) of line 2, col. (c))                              
                                            (see instructions)                                                              (see instructions)

    (1)
    (2)
4   Totals 
5   Corrective action. Attach a detailed statement to describe corrective action taken or to explain why corrective action has not 
    been taken. See instructions. 
          (b) Has corrective 
(a) Act   action been taken?                                                  (c) FMV of amount recovered
number
            Yes          No
(1)
(2)
Part IV     Tax on Coal Mine Operators Under Section 4953. Computation of Section 4953 Tax by the Person 
            Making Excess Contributions Under Section 192 to a Section 501(c)(21) Trust (see instructions)
1   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                 .                  . . .   1a
b   10 tax years .          . .   .     . . . . . .   . .      . . . .        .   . .                  . . .   1b
c   Any  other  funding  period  prescribed  or  approved  by  the  Secretary  of  the
    Treasury .           .  . .   .     . . . . . .   . .      . . . .        .   . .                  . . .   1c
d   Enter the smaller of line 1a or 1b        . . .   . .      . . . .        .   . .                  . . .   1d
e   Enter the larger of line 1c or 1d .       . . .   . .      . . . .        .   . .                  . . . . . .        .  . . .    .       1e
                                                                                                                                        Form 6069 (Rev. 12-2021) 

Form 6069 (Rev. 12-2021)                                                                                                                            Page  3 
Part IV  Tax on Coal Mine Operators Under Section 4953. Computation of Section 4953 Tax by the Person 
         Making Excess Contributions Under Section 192 to a Section 501(c)(21) Trust (see instructions) 
         (continued)
2a   Enter the amount necessary to carry out section 501(c)(21)(A) purposes for the
     tax year .          . . . . . . . .    . . . . . .        . . .   .   . .           . .   2a
b    Enter the fair market value of the trust’s assets. See instructions . . .           . .   2b
c    Subtract line 2b from line 2a. If zero or less, enter -0- . . .   .   . .           . . . . .                 . .   . . .   2c
3a   Contributions made to section 501(c)(21) Trust for operator’s tax year .            . .   3a
b    Operator’s  maximum  allowable  deduction  under  section  192  for  tax  year. 
     Enter the larger of line 1e or line 2c . . . . . .        . . .   .   . .           . .   3b
c    Subtract line 3b from line 3a. If zero or less, enter -0- . . .   .   . .           . .   3c
d    Excess contributions carried over from the preceding tax year     .   . .           . .   3d
e    Total. Add lines 3c and 3d    . . .    . . . . . .        . . .   .   . .           . . . . .                 . .   . . .   3e
4    Amount that current year’s contributions are less than the maximum amount 
     deductible. Subtract line 3a from line 3b. If zero or less, enter -0- . .           . .   4
5    Amount  of  previous  year’s  excess  contributions  that  were  returned  to  the
     contributor during the current tax year  . . . . .        . . .   .   . .           . .   5
6    Total. Add lines 4 and 5 .    . . .    . . . . . .        . . .   .   . .           . . . . .                 . .   . . .   6
7    Excess contributions for current year. Subtract line 6 from line 3e. If zero or less, enter -0- .                   . . .   7
8    Tax imposed on mine operator. Enter 5% (0.05) of line 7 here and in Part I, line 2 .        .                 . .   . . .   8
         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.

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              Signature of trustee                                                                                 Title                        Date

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              Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator                              Date

Sign  
Here     ▲
              Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator                              Date

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              Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator                              Date

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              Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator                              Date

         May the IRS discuss this return with the preparer shown below? See instructions . . . . .                 . .   . . . .        Yes         No
         Print/Type preparer’s name               Preparer’s signature                           Date
Paid                                                                                                                         Check          if  PTIN
                                                                                                                             self-employed 
Preparer                                                                                                                               ▶
         Firm’s name     ▶                                                                                                   Firm’s EIN 
         Firm’s address 
Use Only                     ▶                                                                                               Phone no. 
                                                                                                                                 Form 6069 (Rev. 12-2021)