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Form 6069 (Rev. 2-2012) Page 2
General Instructions black lung benefit trust to which you made Line 5. Enter excess contributions carried over
excess contributions. from the prior tax year that were returned to the
Section references are to the Internal Revenue contributor in the current tax year.
Code unless otherwise noted. Rounding Off to Whole-Dollar Amounts. You
Purpose of Form. Form 6069 is primarily a may show the money items on the return and Line 7. Excess contributions entered on this line
worksheet (Schedule A) used to determine the accompanying schedules as whole-dollar are carried over to the following tax year and
maximum allowable income tax deduction (under amounts. To do so, drop any amount less than treated as a contribution for that tax year.
section 192) for contributions made by coal mine 50 cents and increase any amount from 50 cents Line 8. Make check or money order payable to
operators to tax-exempt black lung benefit through 99 cents to the next higher dollar. For the "United States Treasury" for the full amount
trusts. The form is also used to determine the example, $1.39 becomes $1 and $2.50 due.
amount of excise tax imposed under section becomes $3.
4953 for contributions that are more than the If you have to add two or more amounts to Signature
maximum allowable deduction (see Schedule B). figure the amount to enter on a line, include If you are filing for a corporation, the return must
Who Must File. Any person who has incurred cents when adding the amounts and round off be signed by the president, vice president,
liability for the excise tax on excess only the total. treasurer, assistant treasurer, chief accounting
officer or any other officer (such as tax officer)
contributions under section 4953 must file a Schedule A authorized to sign. If you are filing for a
return on Form 6069. File Form 6069 only to partnership, one general partner must sign. If
report the excise tax liability figured on Schedule If you are completing Schedule A only to figure
B. Do not file it if only Schedule A is completed. the maximum allowable deduction and do not you are filing for a sole proprietorship, the owner
When and Where To File. File Form 6069 by the owe tax on excess contributions, keep this form must sign.
15th day of the 5th month after the end of your with your records instead of filing it with the IRS. If a receiver, trustee in bankruptcy, or assignee
tax year. If the regular due date falls on a Line 1. The determination of amounts necessary is in control of the operator’s property or
Saturday, Sunday, or legal holiday, file on the to cover payments for claims made under the business, that person must sign the return.
next business day. File it with the Internal Black Lung Benefits Acts of 1977 must be based Generally, anyone who is paid to prepare the
Revenue Service, 201 W. River Center Blvd., on reasonable actuarial assumptions. On lines return must sign it and fill in the "Paid Preparer
Covington, KY 41011. 1a, 1b, and 1c, enter the annual amounts you Use Only" area. The signature of the preparer is
To request an extension of time to file Form need to fund (with level funding) all claims not required if the return is prepared by your
6069, file Form 8868, Application for Extension against you that were filed or expected to be regular, full-time employee.
of Time To File an Exempt Organization Return. filed by, or on behalf of, past or present
employees for compensation because of
Accounting Methods. Use the accounting disability or death, due to pneumoconiosis, Privacy Act and Paperwork
method regularly used in keeping your books under the Black Lung Acts. Reduction Act Notice
and records. Line 2a. Enter the total amount paid during the We ask for the information on this form to carry
Accounting Period. Complete the return on the year for any combination of the following: out the Internal Revenue laws of the United
basis of your established accounting period. If States. Section 4953 imposes a tax on excess
you do not have an established accounting • All administrative and other incidental expenses
period, use the calendar year. of operating the trust and processing claims contributions to a Black Lung Benefit Trust. You
against you (including legal, actuarial, and are required to give us the information. Section
Penalties and Interest. There are penalties for trustee expenses). 6109 requires you to provide your taxpayer
late filing, willful failure to file, and for filing identification number (EIN or SSN). We need it to
fraudulent returns and statements. See sections • All direct payments by the trust for claims ensure that you are complying with these laws
6651, 7203, 7206, and 7207. against you. and to allow us to figure and collect the right
Interest at the annual rate provided by law is • All payments of premiums exclusively for amount of tax. Failure to provide this information
charged on any tax shown on line 8, Schedule insurance to cover your liability for claims filed in a timely manner, or providing false
B, that is not paid by the due date of the return. under the Black Lung Acts. information, may subject you to penalties.
• All payments of accident and health benefits for Routine uses of this information include giving it
Definitions retired miners and their spouses and to the Department of Justice for civil and
The term “Black Lung Acts” refers to Part C of dependents to the extent allowed by section criminal litigation, and to cities, states, and the
Title IV of the Federal Mine Safety and Health 501(c)(21)(C). District of Columbia for use in the administration
of their taxes. We may also disclose this
Act of 1977, and any state law that provides Line 2b. Enter the fair market value of the trust’s information to federal and state agencies to
compensation for disability or death due to assets at the beginning of your tax year. enforce federal nontax criminal laws and to
pneumoconiosis (black lung disease). A black
lung benefit claim is a claim for compensation Schedule B combat terrorism.
for disability or death due to pneumoconiosis Complete Schedule B only if your contributions You are not required to provide the information
under the Black Lung Acts. to black lung benefit trusts for the current tax requested on a form that is subject to the
Unless otherwise indicated, the term “trust” as year are more than the maximum allowable Paperwork Reduction Act unless the form
used in the instructions means the tax-exempt deduction under section 192 or if you made displays a valid OMB control number. Books or
section 501(c)(21) trust or trusts to which you excess contributions in the preceding tax year records relating to a form or its instructions must
made contributions for which you claimed a that are carried over to the current tax year. The be retained as long as their contents may
deduction under section 192. contributor must pay a tax in the current tax year become material in the administration of any
on excess contributions carried over from the Internal Revenue law. Generally, tax returns and
Specific Instructions preceding tax year unless the trust returns the return information are confidential, as required by
No deduction is allowed under section 192(a) for excess contributions to the contributor or the Code section 6103.
any contribution to a trust other than a contributor offsets excess contributions by The time needed to complete and file this form
contribution in cash or in items in which the trust reduced contributions in the current tax year. will vary depending on individual circumstances.
may invest under section 501(c)(21)(A)(ii)(II). Line 1a. When an excess contribution is made The estimated average time is:
Payments made for a particular tax year that to a section 501(c)(21) trust in the current tax Recordkeeping . . . . . 7 hr., 10 min.
are made no later than the due date (including year and the trust returns part or all of the Learning about the
extensions) of your income tax return for that tax current year’s excess contribution in the same law or the form . . . . . 1 hr., 17 min.
year are considered to have been made on the year, show only the net contribution for the year Preparing the form . . . . 1 hr., 27 min.
last day of that tax year. on this line (for example, current year’s
Period To Be Covered by Return. Fill in the contribution less current year’s excess Copying, assembling, and
spaces at the top of the form to show the contribution returned). At your request, a black sending the form to the IRS . . . 16 min.
calendar year or fiscal year of the accounting lung benefit trust will repay excess contributions If you have comments concerning the
period you are reporting. (but not more than the excess) made to the trust accuracy of these time estimates or suggestions
for a tax year. The repayment is not an act of for making this form simpler, we would be happy
Name and Address. Enter your name, address, self-dealing or a taxable expenditure reportable to hear from you. You can write to the Internal
and employer identification number in the on Schedule A (Form 990-BL). Revenue Service, Tax Products Coordinating
appropriate spaces. In the spaces for the name Committee, SE:W:CAR:MP:T:M:S, 1111
and employer identification number of the related Line 2. Enter excess contributions carried over Constitution Ave. NW, IR-6526, Washington, DC
trust, enter the identifying information for the from Schedule B, Form 6069 for the previous 20224. Do not send the tax form to this office.
year. Instead, see When and Where To File above.
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