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Department of the Treasury
Internal Revenue Service
Instructions for Form 6069

(Rev. December 2021)
Return of Certain Excise Taxes on Mine Operators, Black Lung Trusts, and Other
Persons Under Sections 4951, 4952, and 4953

Section references are to the Internal Revenue for contributions made to black lung When filer is a coal mine operator. A
Code unless otherwise noted. benefit trusts. Part IV of the form is also coal mine operator completes Part III to
used to determine the amount of excise figure the amount of its allowable
Future Developments tax imposed under section 4953 for contributions for the tax year. The coal
For the latest information about contributions that are more than the mine operator completes Part I and files
developments related to Form 6069 and maximum allowable deduction. Form 6069 only if contributions exceed the
its instructions, such as legislation allowed contribution amount.
enacted after they were published, go to Who Must File
IRS.gov/Form6069. • Any person who is a disqualified person When and Where To File
with respect to a black lung benefit trust File Form 6069 by the 15th day of the 5th
What’s New and has incurred liability for the excise tax month after the end of your tax year. If the
Revised form. Form 6069 has been on self-dealing transactions under section regular due date falls on a Saturday,
substantially reformatted to expand its 4951. Sunday, or legal holiday, file on the next
use. Previously, Form 6069 was used • Any trustee of a black lung benefit trust business day. File it with the:
exclusively by coal mine operators to that has incurred liability for the excise tax
compute their maximum allowable income on the trustee in connection with any Internal Revenue Service Center
tax deduction under section 192 and to self-dealing transaction (section 4951) or 333 W. Pershing Road
determine the amount of any excise tax taxable expenditure (section 4952). Kansas City, MO 64108
imposed under section 4953 for • Any black lung benefit trust that has
contributions that exceed the allowable incurred liability for the excise tax on To request an extension of time to file
deduction. For tax years beginning on or taxable expenditures (under section Form 6069, file Form 8868, Application for
after January 1, 2021, Form 6069 will also 4952). Automatic Extension of Time To File an
be used by section 501(c)(21) black lung • Any coal mine operator that made Exempt Organization Return.
benefit trusts to report and pay excise excess contributions (under section 4953)
taxes imposed under section 4951 must file Form 6069. A coal mine operator
(self-dealing) and 4952 (taxable can complete Part IV, lines 1 through 7, to Accounting Methods
expenditures). figure the maximum allowable deduction Use the accounting method regularly used
under section 192. Form 6069 must be in keeping your books and records.
filed only if the amount shown on Part IV,
General Instructions line 7, is greater than zero. Accounting Periods
A coal mine operator should not Complete the return on the basis of your
established accounting period. If you do
Purpose of Form ! file Form 6069 if the information not have an established accounting
Black lung benefit trusts and certain CAUTION entered in Part IV indicates that no
other persons. The Black Lung Benefits excess contributions were made. period, use the calendar year.

Revenue Act of 1977 (the Act) amended Penalties and Interest
the Code to impose an excise tax on the Which Parts To Complete There are penalties for late filing, willful
sale of coal and established a trust fund
under section 501(c)(21) (funded by the When filer is a black lung benefit trust. failure to file, and for filing fraudulent
coal tax and certain other revenues) to be A trust filing this form for a year in which returns and statements. See sections
available for expenses of providing there are initial taxes due under section 6651, 7203, 7206, and 7207. Also see
medical benefits when not paid by the 4951 or 4952 completes Form 6069 as section 6684 for penalties that relate to
appropriate mine operator. The Act also follows. excise tax liability under chapter 42.
added sections 4951 (self-dealing), 4952 • Complete Parts II and III first, providing Interest charges for any unpaid tax are
(taxable expenditures), and 4953 (excess complete information about the charged at the underpayment rate
contributions by mine operators) to self-dealing and taxable expenditure established under section 6621. The
impose excise taxes on certain acts. For transactions and showing tax interest on underpayments is in addition to
tax years beginning on or after January 1, computations. any penalties.
2021, black lung benefit trusts will use • Complete Part I, line 1, only. Do not
Form 990 to meet reporting requirements include taxes that must be paid by the Definitions
under section 6033. If initial taxes are trustee or a self-dealer on any other line in The term “Black Lung Acts” refers to Part
imposed on the trust or certain related Part I. C of Title IV of the Federal Mine Safety
parties under section 4951 or 4952, the When filer is a self-dealer. A self-dealer and Health Act of 1977, and any state law
trust or related party will report the initial liable for initial taxes under section 4951 that provides compensation for disability
excise tax using Part II or Part III, completes Part II, then Part I. or death due to pneumoconiosis (black
respectively, of Form 6069. lung disease). A black lung benefit claim is
When filer is a trustee. A trustee liable a claim for compensation for disability or
Coal mine operators. A coal mine for initial excise taxes (sections 4951 and death due to pneumoconiosis under the
operator will now use Part IV of Form 6069 4952) completes Parts II and III (as Black Lung Acts. Unless otherwise
to determine the maximum allowable applicable), and then Part I. indicated, the term “trust” as used in these
income tax deduction (under section 192)

Dec 15, 2021 Cat. No. 749870

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instructions means the tax-exempt section        2. The date on which the tax imposed      account under section 267(c), except that, 
501(c)(21) trust or trusts to which the coal  by section 4951(a)(1) is assessed; or        for purposes of this paragraph, section 
mine operator made contributions for             3. The date on which correction of the    267(c)(4) is treated as providing that the 
which it claimed a deduction under section    act of self-dealing is completed.            members of the family of an individual are 
192.                                                                                       only those individuals described in item 5. 
                                              Amount involved.       The term “amount      For purposes of items 3b and c, 7, and 8, 
Self-Dealing (Section 4951)                                                                the ownership of profits or beneficial 
                                              involved” means, for any act of 
Self-dealing. For purposes of section         self-dealing, the greater of the amount of   interests is determined by the rules for 
4951, the term “self-dealing” means any       money and the fair market value (FMV) of     constructive ownership of stock provided 
direct or indirect:                           the other property given or the amount of    in section 267(c) (other than paragraph 
• Sale, exchange, or leasing of real or       money and the FMV of the other property      (3)), except that section 267(c)(4) is 
personal property between a trust             received. However, in the case of services   treated as providing that the members of 
described in section 501(c)(21) and a         described in section 4951(d)(2)(C), the      the family of an individual are only those 
disqualified person;                          amount involved is only the excess           individuals described in item 5.
• Lending of money or other extension of      compensation. For purposes of the            Payment of benefits.     For purposes of 
credit between such a trust and a             preceding sentence, the FMV:                 section 4951, a payment out of assets or 
disqualified person;                             1. For the initial taxes imposed by       income of a trust described in section 
• Furnishing of goods, services, or           section 4951(a), is determined as of the     501(c)(21) for the purposes described in 
facilities between such a trust and a         date on which the act of self-dealing        sections 501(c)(21)(A)(i)(I) and 501(c)(21)
disqualified person;                          occurs; and                                  (A)(i)(IV) is not considered an act of 
• Payment of compensation (or payment                                                      self-dealing.
or reimbursement of expenses) by such a          2. For additional taxes imposed by 
trust to a disqualified person; and           section 4951(b), is the highest FMV during   Taxable Expenditures (Section 
• Transfers to, or use by or for the benefit  the taxable period.
                                                                                           4952)
of, a disqualified person of the income or    Correction. The terms “correction” and       Taxable expenditure.     For purposes of 
assets of such a trust.                       “correct” mean, for any act of self-dealing, section 4952, the term “taxable 
Special rules. For purposes of section        undoing the transaction to the extent        expenditure” means any amount paid or 
4951:                                         possible, but in any case, placing the trust incurred by a trust described in section 
• The transfer of personal property by a      in a financial position not worse than that  501(c)(21) other than for a purpose 
disqualified person to such a trust is        in which it would be if the disqualified     specified in that section.
treated as a sale or exchange if the          person were dealing under the highest 
property is subject to a mortgage or similar  fiduciary standards.                         Correction.  The terms “correction” and 
                                                                                           “correct” mean, with respect to any 
lien;                                         Disqualified person.      The term           taxable expenditure, placing the trust in a 
• If a bank or an insured credit union is a   “disqualified person” means, for a trust     financial position not worse than that in 
trustee of the trust or otherwise is a        described in section 501(c)(21), a person    which it would have been if the taxable 
“disqualified person” with respect to the     who is:                                      expenditure had not been made:
trust, any amount invested in checking 
accounts, savings accounts, certificates of      1. A contributor to the trust;            1. By recovering all or part of the 
deposit, or other time or demand deposits        2. A trustee of the trust;                expenditure to the extent recovery is 
in that bank or credit union constitutes a       3. An owner of more than 10% of:          possible; and
lending of money;                                                                          2. When full recovery is not possible, 
• The furnishing of goods, services, or          a. The total combined voting power of 
facilities by a disqualified person to such a a corporation,                               by contributions by the person or persons 
                                                                                           whose liabilities for black lung benefit 
trust is not an act of self-dealing if the       b. The profits interest of a partnership, claims (as defined in section 192(e)) are to 
furnishing is without charge and if the       or                                           be paid out of the trust.
goods, services, or facilities so furnished      c. The beneficial interest of a trust or 
are used exclusively for the purposes         unincorporated enterprise that is a          Taxable period. The term “taxable 
specified in section 501(c)(21)(A); and       contributor to the trust;                    period” means, with respect to any taxable 
• The payment of compensation (and the                                                     expenditure, the period beginning with the 
                                                 4. An officer, director, or employee of 
payment or reimbursement of expenses)                                                      date on which the taxable expenditure 
                                              a person who is a contributor to the trust;
by such a trust to a disqualified person for                                               occurs and ending on the earlier of:
personal services that are reasonable and        5. The spouse, ancestor, lineal 
necessary to carry out the exempt             descendant, or spouse of a lineal            1. The date of mailing a notice of 
purpose of the trust is not an act of         descendant of an individual described in     deficiency under section 6212, with 
self-dealing if the compensation (or          (1), (2), (3), or (4);                       respect to the tax imposed by section 
                                                                                           4952(a)(1); or
payment or reimbursement) is not                 6. A corporation of which persons 
excessive. See Regulations section            described in (1), (2), (3), (4), or (5) own  2. The date on which the tax imposed 
53.4951-1 for additional information.         more than 35% of the total combined          by section 4952(a)(1) is assessed.
Taxable period.     The term “taxable         voting power;
period” means, with respect to any act of        7. A partnership in which persons         Specific Instructions
self-dealing, the period beginning with the   described in (1), (2), (3), (4), or (5) own 
date on which the act of self-dealing         more than 35% of the profits interest; or    Items A Through I
occurs and ending on the earliest of:            8. A trust or estate in which persons 
  1. The date of mailing of a notice of       described in (1), (2), (3), (4), or (5) hold Item A. Fill in the spaces to show the 
deficiency under section 6212, with           more than 35% of the beneficial interest.    calendar year or fiscal year of the 
                                                                                           accounting period you are reporting.
respect to the tax imposed by section            For purposes of items 3a and 6 above,     A black lung benefit trust filing to report 
4951(a)(1);                                   indirect stockholdings are taken into        taxable expenditures (section 4952) 
                                              account if they would be taken into 

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should enter the calendar or fiscal year of the next dollar. For example, $1.39 person (other than a trustee acting only as
the trust. becomes $1 and $2.50 becomes $3. such) who participated in the act of
self-dealing.
Disqualified persons and trustees who If you have to add two or more amounts
participate in acts of self-dealing with a to figure the amount to enter on a line, Initial section 4951 taxes on trustee.
black lung benefit trust and who have tax include cents when adding the amounts When a tax is imposed on an act of
years different from the trust should use and round off only the total. self-dealing, any trustee who knowingly
their own tax years to figure the initial tax participated in such an act must pay a tax
and file the return. of 2.5% of the amount involved in the act
Part I. Tax and Payment
A coal mine operator filing Form 6069 of self-dealing for each year (or part of a
to report the excise tax on excess Lines 1 through 5. See the specific line year) in the taxable period unless
contributions (section 4953) should enter instructions for Parts II through IV for participation in the act was not willful and
the calendar or fiscal year of the coal mine instructions applicable to each type of filer was due to reasonable cause.
operator. regarding amounts to be entered in Part I, Line 1. List each act of self-dealing on
lines 1 through 5.
Item B. Check box (1) if you are a black line 1, providing the date and a brief
lung benefit trust liable for the section A coal mine operator should complete description of each act in columns (b) and
4952 tax on taxable expenditures. Part I and file Form 6069 only if the (c).
amount carried to Part I, line 2, from Part
Check the appropriate box(es) on line IV, line 8, is greater than zero. Line 2. For each act of self-dealing listed
(2) if you are one or more of the following. on line 1, provide the following
• A disqualified person liable for the Liability for tax. A person's liability for information.
section 4951 excise tax on self-dealing. tax as a self-dealer or trustee under • In column (b), enter the names of all
• A trustee of a black lung benefit trust sections 4951 and 4952 is joint and disqualified persons who took part in the
and are liable for the excise tax arising several. Therefore, if more than one acts of self-dealing listed on line 1.
from your role in connection with a person is liable for tax on an act of • In column (c), enter the amount
self-dealing transaction (section 4951) or self-dealing as a self-dealer or trustee, involved in each act of self-dealing.
taxable expenditure (section 4952). they may prorate the tax among For each act of self-dealing, multiply
• A coal mine operator liable for the themselves. The IRS may assess a the amount in column (c) by 0.10 and
section 4953 excise tax on excess deficiency against one or more enter the amount in column (d). If more
contributions to a black lung benefit trust. self-dealers or trustees liable for the tax than one disqualified person took part in
under section 4951 or 4952, regardless of an act of self-dealing, each disqualified
Item C. Enter your name and address in the apportionment of tax shown on the person is individually liable for the entire
the appropriate spaces. return, if the amount paid by all those who amount of the tax. Nonetheless, the
Item D. Enter your taxpayer identification are liable for a particular transaction is less disqualified persons who are liable for the
number (TIN) (employer identification than the total tax due for that transaction. tax may prorate the payment among
number (EIN) or social security number All other filers report and compute tax themselves. If self-dealers prorate the
(SSN)). A filer other than the black lung owed on Part I. Payment by a black lung excise tax, attach a statement showing the
benefit trust should not enter the trust’s benefit trust of any taxes owed by any intended allocation of liability among the
EIN here. trustee or self-dealer will result in self-dealers.
Item E. Check the “Amended return” box additional taxes under the self-dealing For each act of self-dealing, multiply
if the filer previously filed a Form 6069 (section 4951) and taxable expenditure the amount in column (c) by 0.025 and
return with the IRS for a tax year and is (section 4952) provisions. Trustees and enter the amount in column (e). A trustee
now filing another return for the same tax self-dealers should pay taxes imposed on who took part in the act of self-dealing and
year to amend the previously filed return. them from their own funds. who knew that the act was self-dealing
Complete the entire return (not just the Tax payments can be made by check (except for trustees whose participation
part that changed) following the form and or through the Electronic Federal Tax was not willful and was due to reasonable
instructions for the amended year. Include Payment System (EFTPS). For more cause) is liable for the tax in column (e).
a statement that identifies the lines and information about EFTPS or to enroll in If more than one trustee took part in the
amounts being changed and the reason EFTPS, visit the EFTPS website at act of self-dealing, knowing that it was
for each change. EFTPS.gov, or call 800-555-4477. You such an act, and participation was willful
Items F and G. If you checked a box on can also get Pub. 966, Electronic Federal and not due to reasonable cause, each is
line (2) of Item B, enter the name on Item Tax Payment System: A Guide to Getting individually liable for the entire tax in
F and EIN on Item G of the black lung Started. connection with the act. Nonetheless, the
benefit trust to which the excise taxes trustees liable for the excise tax may
being reported relate. Part II. Initial Taxes on prorate the payment among themselves.
Items H and I. In Item H, enter the name Self-Dealing Attach a statement showing the name of
and address of the person who has the Disqualified persons and trustees who each trustee liable for the tax in column (e)
filer's books and records. In Item I, enter participate in acts of self-dealing with a for each act of self-dealing.
the telephone number at which he or she black lung benefit trust and who have tax Line 3. Enter on line 3d the total initial tax
can be reached. years different from the trust should use on the self-dealer(s) computed on line 2d.
their own tax years to figure the initial tax Enter on line 3e the total initial tax on the
Rounding Off to Whole and file the return. trustee(s) computed on line 2e.
Dollar Amounts Initial section 4951 taxes on self-deal- For a Form 6069 filed by the trust.
You can round off cents to whole dollars er. An initial tax of 10% of the amount Do not carry amounts from Part II to Part I.
on your return. If you do round to whole involved is imposed for each act of The trust completes Part II to provide
dollars, you must round all amounts. To self-dealing between a disqualified person information on the self-dealing
round, drop amounts under 50 cents and and a black lung benefit trust, for each transactions, but must not pay the tax for
increase amounts from 50 to 99 cents to year (or part of a year) in the taxable which self-dealers and trustees are liable.
period. The tax is paid by any disqualified

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For a Form 6069 filed by a trustee who took part in the taxable filed or expected to be filed by, or on
self-dealer. The filer should enter the expenditure and who knew that the act behalf of, past or present employees for
amount shown on line 3d, in Part I, line 3a. was a taxable expenditure (except for compensation because of disability or
In Part I, line 3b, indicate the percentage trustees whose participation was not willful death, due to pneumoconiosis, under the
of the amount reported on line 3a and was due to reasonable cause) is liable Black Lung Acts.
apportioned to the filer. Attach a statement for the tax in column (c).
Line 2a. Enter the total amount paid
showing detail for proration of the excise If more than one trustee took part in the during the year for any combination of the
tax on the self-dealing transactions among taxable expenditure, knowing that it was following.
the self-dealers. such an act, and participation was willful • All administrative and other incidental
For a Form 6069 filed by a trustee. and not due to reasonable cause, each is expenses of operating the trust and
The filer should enter the amount shown individually liable for the entire tax in processing claims against the coal mine
on line 3e, in Part I, line 4a. In Part I, connection with the act. Nonetheless, the operator (including legal, actuarial, and
line 4b, indicate the percentage of the trustees liable for the excise tax may trustee expenses).
amount reported on line 4a apportioned to prorate the payment among themselves. • All direct payments by the trust for
the filer. Attach a statement showing detail Attach a statement showing the name of claims against the coal mine operator.
for proration of the excise tax on each trustee liable for the tax in column • All payments of premiums exclusively
self-dealing among the trustees. (iii) for each taxable expenditure. for insurance to cover the coal mine
Line 4. Corrective action. The trust and Line 4. Enter on line 4b the total initial tax operator’s liability for claims filed under the
each self-dealer filing Form 6069 to report on the trust computed on line 3b. Enter on Black Lung Acts.
a self-dealing transaction should describe line 4c the total initial tax on the trustee(s) • All payments of accident and health
corrective action taken (or not taken) in computed on line 3c. benefits for retired miners and their
spouses and dependents to the extent
connection with each self-dealing For a Form 6069 filed by the trust. allowed by section 501(c)(21)(C).
transaction. In the case of self-dealers and Enter the amount shown in line 4b, in Part
trustees, the information provided for I, line 1. Line 2b. Enter the FMV of the trust’s
line 4 should be limited to transactions for assets at the beginning of the coal mine
which the filer incurred excise tax liability For a Form 6069 filed by a trustee. operator’s tax year.
under section 4951. The filer should enter the amount shown
Line 3a. When an excess contribution is
on line 4c, in Part I, line 5a. In Part I,
made to a black lung benefit trust in the
Part III. Initial Taxes on line 5b, indicate the percentage of the
current tax year and the trust returns part
amount reported on line 5a apportioned to
or all of the current year’s excess
Taxable Expenditures and the filer. Attach a statement showing detail
contribution in the same year, show only
Tax Computation for the proration of the excise tax on
the net contribution for the year on this line
taxable expenditures among the trustees.
Initial section 4952 taxes on trust. An (for example, current year’s contribution
initial tax of 10% of the amount of the Line 5. Corrective action. The trust less current year’s excess contribution
expenditure is imposed on each taxable should describe corrective action taken (or returned). At your request, a black lung
expenditure from the assets of a black not taken) in connection with each taxable benefit trust will repay excess
lung benefit trust. The tax is paid from expenditure. contributions (but not more than the
assets of the trust. excess) made to the trust for a tax year.
Initial section 4952 taxes on trustee. Part IV. Tax on Coal Mine The repayment is not an act of self-dealing
or a taxable expenditure.
When a tax is imposed on the trust for a Operators Under Section
Line 3d. Enter excess contributions
taxable expenditure, any trustee who 4953
knowingly agreed to the expenditure must carried over from the previous year.
If you are a coal mine operator completing
pay a tax of 2.5% of the amount of the Line 5. Enter excess contributions carried
Form 6069 only to figure the maximum
taxable expenditure, unless such over from the prior tax year that were
allowable deduction under section 192
agreement was not willful and was due to returned to the contributor in the current
and do not owe tax on excess
reasonable cause. tax year.
contributions, keep this form with your
Line 1. List each taxable expenditure on records instead of filing it with the IRS. Line 7. Excess contributions entered on
line 1, providing the name and address of this line are carried over to the following
the recipient of cash or other property No deduction is allowed under section
distributed for other than a purpose 192(a) for any contribution to a trust other tax year and treated as a contribution for
described in section 501(c)(21) in column than a contribution in cash or in items in that tax year.
(b); and a brief description of each which the trust may invest under section Line 8. If the amount on line 7 is greater
expenditure in column (c). 501(c)(21)(A)(ii)(II). than zero, multiply that amount by 0.05
Line 2. For each taxable expenditure, Payments made for a particular tax and enter the amount here and on Part I,
provide the date the expenditure was paid year that are made no later than the due line 2.
or incurred (column (b)), the amount date (including extensions) of the mine
(column (c)), and the name of each trustee operator’s income tax return for that tax Signature and Verification
liable for the excise tax (column (d)). year are considered to have been made Form 6069 filed by a black lung benefit
on the last day of that tax year. trust should be signed by the trustee using
Line 3. For each taxable expenditure, the top signature area. Form 6069 filed by:
multiply the amount on line 2, column (c), Line 1. The determination of amounts
by 0.10 and enter the amount in column necessary to cover payments for claims • A trustee liable for the excise tax on a
(b). The black lung benefit trust is liable for made under the Black Lung Benefits Acts trustee’s participation in an act of
the excise tax shown in column (b). of 1977 must be based on reasonable self-dealing (section 4951) or a taxable
actuarial assumptions. On lines 1a, 1b, expenditure (section 4952),
For each taxable expenditure, multiply and 1c, enter the annual amounts needed • A self-dealer liable for the excise tax
the amount on line 2, column (c), by 0.025 to fund (with level funding) all claims under section 4951, or
and enter the amount in column (c). A against the coal mine operator that were

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• A mine operator liable for the excise tax    • Give a copy of the return to the           black lung benefit trust. You are required 
on excess contributions under section          organization, in addition to the copy to be  to give us the information. Section 6109 
4953,                                          filed with the IRS.                          requires you to provide your taxpayer 
should be signed using the signature line                                                   identification number (EIN or SSN). We 
                                                        Any paid preparer whose 
below the signature line used by the black                                                  need it to ensure that you are complying 
                                                        identifying number must be listed 
lung benefit trust.                            CAUTION!                                     with these laws and to allow us to figure 
                                                        on Form 6069 can apply for and 
                                                                                            and collect the right amount of tax. Failure 
  If you are signing on behalf of the black    obtain a PTIN. You can apply for a PTIN 
                                                                                            to provide this information in a timely 
lung benefit trust and also because of         online or by filing Form W-12, IRS Paid 
                                                                                            manner, or providing false information, 
personal tax liability, you must file two      Preparer Tax Identification Number (PTIN) 
                                                                                            may subject you to penalties. Routine 
Forms 6069.                                    Application and Renewal. For more 
                                                                                            uses of this information include giving it to 
  For a corporation (or an association),       information about applying for a PTIN 
                                                                                            the Department of Justice for civil and 
the form may be signed by one of the           online, visit the IRS website at IRS.gov/
                                                                                            criminal litigation, and to cities, states, and 
following: president, vice president,          PTIN.
                                                                                            the District of Columbia for use in the 
treasurer, assistant treasurer, chief                                                       administration of their taxes. We may also 
accounting officer, or other corporate         Paid Preparer                                disclose this information to federal and 
officer (such as tax officer). For a                                                        state agencies to enforce federal nontax 
partnership, the form may be signed by a       Authorization                                criminal laws and to combat terrorism.
partner or partners authorized to sign the     On the “Sign Here” line, check “Yes” if the 
partnership return.                            IRS can contact the paid preparer who        You are not required to provide the 
                                               signed the return to discuss the return.     information requested on a form that is 
  If the return is filed on behalf of a trust, This authorization applies only to the       subject to the Paperwork Reduction Act 
the authorized trustee(s) must sign it.        individual whose signature appears in the    unless the form displays a valid OMB 
  A receiver, trustee, or assignee             Paid Preparer Use Only section of Form       control number. Books or records relating 
required to file any return on behalf of an    6069. It doesn't apply to the firm, if any,  to a form or its instructions must be 
individual, trust, estate, partnership,        shown in that section.                       retained as long as their contents may 
association, company, or corporation must                                                   become material in the administration of 
sign the Form 6069 filed for these               By checking the “Yes” box, the 
taxpayers. Also, a person with a valid         organization is authorizing the IRS to       any Internal Revenue law. Generally, tax 
power of attorney may sign for the section     contact the paid preparer to answer any      returns and return information are 
501(c)(21) trust, trustee, self-dealer, or     questions that arise during the processing   confidential, as required by Code section 
mine operator. Include a copy of the           of the return. The organization is also      6103.
power of attorney with the return.             authorizing the paid preparer to:
                                                                                            The time needed to complete and file 
                                               • Give the IRS any information missing 
                                                                                            this form will vary depending on individual 
                                               from the return;
                                                                                            circumstances. The estimated average 
Attachments                                      Call the IRS for information about 
                                               •                                            time is:
If you need more space, attach separate        processing the return; and
sheets showing the same information in         • Respond to certain IRS notices about       Recordkeeping. . . . .    7 hr., 10 min.
the same order as on the printed form.         math errors, offsets, and return 
Show the totals on the printed form.           preparation.                                 Learning about the 
  On each sheet, enter the name and TIN                                                     law or the form. . .      1 hr., 17 min.
of the person or entity filing Form 6069.        The organization isn't authorizing the 
Also include the name and EIN of the           paid preparer to bind the organization to    Preparing the 
section 501(c)(21) black lung trust, and, if   anything or otherwise represent the          form. . . . . . . . . . . 1 hr., 27 min.
applicable, the name and TIN of the            organization before the IRS.
                                                                                            Copying, 
trustee, self-dealer, or mine operator on        The authorization will automatically end   assembling, and 
each sheet. Use sheets that are the same       no later than the due date (excluding        sending the form 
size as the form and indicate clearly the      extensions) for filing of the Form 6069 for  to the IRS. . . . . . .            16 min.
line of the paper form to which the            the next tax year. If the organization wants 
information relates.                           to expand the paid preparer's 
                                               authorization or revoke it before it ends, 
Paid Preparer                                  see Pub. 947, Practice Before the IRS and    If you have comments concerning the 
Generally, anyone who is paid to prepare       Power of Attorney.                           accuracy of these time estimates or 
the return must sign the return and fill in      Check “No” if the IRS should contact       suggestions for making this form simpler, 
the other blanks in the Paid Preparer Use      the organization listed on the first page of we would be happy to hear from you. You 
Only area. An employee of the filing           the Form 6069 rather than the paid           can send us comments through IRS.gov/
organization isn't a paid preparer.            preparer.                                    FormComments. Or you can write to the 
  The paid preparer must:                                                                   Internal Revenue Service, Tax Forms and 
• Sign the return in the space provided        Privacy Act and Paperwork Reduction          Publications, 1111 Constitution Ave. NW, 
for the preparer's signature;                  Act Notice.  We ask for the information on   IR-6526, Washington, DC 20224. Don’t 
• Enter the preparer information;              this form to carry out the Internal Revenue  send the tax form to this office. Instead, 
• Enter the preparer tax identification        laws of the United States. Section 4953      see When and Where To File, earlier.
number (PTIN); and                             imposes a tax on excess contributions to a 

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