Form  990-BL                                                          Information and Initial Excise Tax Return for Black 
(Rev. December 2013)                                                    Lung Benefit Trusts and Certain Related Persons                                                      OMB No. 1545-0049 
Department of the Treasury                                                             Under section 501(c)(21) of the Internal Revenue Code.
Internal Revenue Service                                    ▶ Information about Form 990-BL and its instructions is available at www.irs.gov/form990bl.
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 .     .  ▶
                                                                                                                                              If address changed, check here .   .     .  ▶
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 .          . . . . .   . . . .        . . . . . .             . . .  . .      . .      1 
                                                2    Investment income: 
                                                a    Interest on certain securities of the U.S., state, and local governments             . . .  . .      . .    2a 
                                                b    Interest  on  time  or  demand  deposits  in  a  bank  or  insured  credit  union  (described  in
                                                     section 501(c)(21)(D)(ii)(III)) .   . . . .   . . . .        . . . . . .             . . .  . .      . .    2b 
                                                c    Gross amount received from sale of assets       . . .        . . . . .
                        Revenue                      Less cost or other basis and sales expenses .     . .        . . . . .  
                                                     Net gain or (loss) .       .    . . . . . .   . . . .        . . . . . .             . . .  . .      . .    2c 
                                                d    Other income (attach schedule) .        . .   . . . .        . . . . . .             . . .  . .      . .    2d 
                                                3    Total revenue (add lines 1 through 2d) .      . . . .        . . . . . .             . . .  . .       ▶       3 
                                                4    Contributions to the Federal Black Lung Disability Trust Fund      . . .             . . .  . .      . .      4 
                                                5    Premiums  for  insurance  to  cover  liabilities  described  in  section  501(c)(21)(A)(i)(I)  and 
                                                     501(c)(21)(A)(i)(IV) .     .    . . . . . .   . . . .        . . . . . .             . . .  . .      . .      5 
                                                6    Other payments to or for benefit of eligible coal miners, retired miners, or beneficiaries  .          .      6 
                                                7    Compensation of trustees .          . . . .   . . . .        . . . . . .             . . .  . .      . .      7 
                                                8    Other salaries and wages .          . . . .   . . . .        . . . . . .             . . .  . .      . .      8 
                        Expenses 
                                                9    Administrative expenses not included on lines 7 and 8 (attach schedule) .              . .  . .      . .      9 
                                                10   Other expenses (attach schedule)        . .   . . . .        . . . . . .             . . .  . .      . .    10 
                                                11   Total expenses (add lines 4 through 10)       . . . .        . . . . . .             . . .  . .      . .    11 
                                                12   Excess of revenue over expenses (subtract line 11 from line 3) .     . .             . . .  . .       ▶     12 
Part II                                              Balance Sheets                                                                              Beginning of year           End of year 
                                                13   Cash . .         . . .     . .    . . . . .   . . . .        . . . . .                13 
                                                14   Savings and interest-bearing accounts .       . . . .        . . . . .                14 
                                                15   Investments in approved securities .      .   . . . .        . . . . .                15 
                        Assets                  16   Office supplies and equipment         . . .   . . . .        . . . . .                16 
                                                17   Other assets (attach schedule)        . . .   . . . .        . . . . .                17 
                                                18   Total assets (add lines 13 through 17) .      . . . .        . . . . . ▶              18 
                                                19   Liabilities (see instructions) .    . . . .   . . . .        . . . . .                19 
                                                20   Net assets .       . .     .    . . . . . .   . . . .        . . . . .                20 
                                 and 
            Liabilities              Net Assets 21   Total liabilities and net assets (add lines 19 and 20) .     . . . . . ▶              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)  .                                                      . . .  . .      . .  .      .    .     Yes      No
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                                                            Cat. No. 10315Y      Form  990-BL  (Rev. 12-2013) 

Form 990-BL (Rev. 12-2013)                                                                                                                 Page  2 
Part III  Questionnaire                                                                                                                Yes  No 
22   Have you made any changes not previously reported to the Internal Revenue Service in your governing instrument, 
     or other similar instrument? .    . .  . . . .    .  . .       . .   . .      .   .  . . .   . .         . . . .   .  .      . .
23   If “Yes,” attach a conformed copy of the changes. 
     Taxes on self-dealing (section 4951): 
   a During the year did the trust (either directly or indirectly): 
     (1)  Engage in the sale, exchange, or leasing of property with a disqualified person?        . .         . . . .   .  .      . .  
     (2)  Borrow or lend money or otherwise extend credit to (or accept it from) a disqualified person? .           .   .  .      . .  
     (3)  Furnish goods, services, or facilities to (or accept them from) a disqualified person? .            . . . .   .  .      . .  
     (4)  Pay compensation to, or pay or reimburse expenses of, a disqualified person? .          . .         . . . .   .  .      . .  
     (5)  Transfer any income or assets to, or for use by or for the benefit of, a disqualified person? .         . .   .  .      . .  
   b If  the  answer  is  “Yes”  to  any  of  questions  23a(1)  through  23a(5),  were  all  of  the  acts  in  which  you  engaged 
     excepted acts as described in the instructions? .    . .       . .   . .      .   .  . . .   . .         . . . .   .  .      . .
   c If the answer is “No” to question 23b, complete Schedule A (Form 990-BL), Part I, Section A. 
24   Taxes on taxable expenditures (section 4952): During the year did you pay, or incur a liability to pay, any amount 
     for  any  purpose  other  than  for  payment  of: (1)  black  lung  benefits,   (2)  administrative  expenses  of  the  trust, 
     (3)  premiums  for  insurance  covering  liabilities  for  black  lung  benefits, (4)  permitted  benefits  for  retired  miners, 
     their  spouses,  and  dependents,   (5)  permitted  investments  of  trust  funds,   (6)  transfer  of  funds  to  the  Federal 
     Black Lung Disability Fund or to the general fund of the U.S. Treasury, or           (7) return of excess contributions to 
     the coal mine operator who contributed them?.     .  . .       . .   . .      .   .  . . .   . .         . . . .   .  .      . .
     If the answer is “Yes,” complete Schedule A, Form 990-BL, Part I, Section B. 
25   Have you taken corrective action for any transaction that resulted in Chapter 42 taxes being reported on Schedule 
     A, Form 990-BL?         . .   . . . .  . . . .    .  . .       . .   . .      .   .  . . .   . .         . . . .   .  .      . .
     If “Yes,” attach a detailed documentation and description of the corrective action taken and, if applicable, enter 
     the fair market value of any property recovered as a result of the correction.  ▶        $ 
     For any uncorrected acts, attach explanation (see instructions). 
26   Officers, directors, trustees and their compensation, if any, for the tax year: 
                               (a)                                    (b)                (c)  Contributions         (d)                (e) 
                Name and Address                                    Title and time     to employee benefit        Expense           Compensation 
                                                            devoted to position             plans               account, other       (If not paid, 
                                                                                                                allowances           enter zero.) 

Total . . . . . .          . . .   . . . .  . . . .    .  . .       . .   . .      .   .  . . .   . .         . . . .   .  ▶

Part IV   Statement With Respect to Contributors, etc. —  (Not open for public inspection) 
1    Persons who contributed $5,000 or more in the taxable year (if more space is needed, attach schedule): 
                               Name                                                                 Address 

2    During  the  period  covered  by  this  return  did  the  trust  receive  any  contributions  in  excess  of  the  maximum        Yes  No 
     allowable deduction for the contributor under section 192?       .   . .      .   .  . . .   . .         . . . .   .  .      . .  
                                                                                                                    Form  990-BL  (Rev. 12-2013) 

Form 990-BL (Rev. 12-2013)                                                                                                                              Page  3 
Schedule A—Initial Excise Taxes on Black Lung Benefit Trusts and Certain Related Persons 
            Under sections 4951 and 4952 of the Internal Revenue Code 
                                              NOT OPEN FOR PUBLIC INSPECTION 
For the calendar year            , or fiscal year beginning                           ,           , and ending                                   , 
Name of trust/person filing return (see instructions)                                                             EIN or SSN of filer (see instructions) 

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

Return filed by (see instructions, check box that applies):     Trust                                               Trustee 
                                                                Disqualified person 
Part I     Initial Taxes on Self-dealing (Section 4951) and Taxable Expenditures (Section 4952) 
                                 SECTION A—Acts of Self-dealing and Tax Computation (Section 4951) 
(a) Act    (b) Date of act                                                    (c) Description of act 
number 
1 
2 
3 
4 
           (d) Names of disqualified persons liable for tax                                     (e) Names of trustees liable for tax 

         (f) Amount involved in act                         (g) Initial tax on self-dealing disqualified person          (h) Tax on trustee (if applicable) 
                                                                        (10% of column (f))                                         (2½% of column (f)) 

Total (add lines  1through   4,  
columns (g) and (h)) .     . .   .  . .  ▶
                                SECTION B—Taxable Expenditures and Tax Computation (Section 4952) 
(a) Item   (b) Amount           (c) Date paid               (d) Name and address of recipient                       (e) Description of expenditure and 
number                           or incurred                                                                          purposes for which made 
1 
2 
3 
4 
                                 (f) Names of trustees liable for tax                               (g) Tax imposed on trust              (h) Tax imposed on 
                                                                                                                (10% of column (b))       trustee (if applicable) 
                                                                                                                                          (2½% of column (b)) 

Total (Add lines  1through   4, columns (g) and (h)) .        . .     . . . . .     . .       .  ▶
Part II    Summary of Taxes 

1     Enter amount of section 4951 tax on disqualified person from Part I, Section A, column (g)                            1 

2     Enter amount of section 4951 tax on trustee from Part I, Section A, column (h) .              .           . . .  .    2 

3     Enter amount of section 4952 tax on trust from Part I, Section B, column (g) .              . .           . . .  .    3 

4     Enter amount of section 4952 tax on trustee from Part I, Section B, column (h) .              .           . . .  .    4 

5     Total tax due (add lines  1through  4) .        .     . . .     . . . . .     . .       . . . .           . . .  ▶    5 
                                                                                                                                    Form  990-BL  (Rev. 12-2013)