Return of Excise Tax on Excess Contributions to                                                         OMB No. 1545-0049
Form   (Rev. February 2012)6069   Black Lung Benefit Trust Under Section 4953 and 
                                                                                                                                            NOT Open for 
Department of the Treasury                 Computation of Section 192 Deduction                                                             Public Inspection
Internal Revenue Service 
For calendar year                 , or fiscal year beginning                                                , and ending 
Operator’s name                                                                                             Employer identification number 

Number, street, and room or suite no. (or P. O. box number) 
                                                                                                            If address changed, check here  .          . .   . .  ▶
City or town, state and ZIP code 

Name of related section 501(c)(21) trust                                                                    Employer identification number of related trust 

Schedule A                 Worksheet for Computing the Section 192 Deduction by Coal Mine Operators (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 

2 a    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 less than zero, enter -0-)              . .    .    . .       .  . .   .      . . .    .     2c 

3      Maximum allowable deduction (enter the larger of line 1e or line 2c)                    .       .  . .   .      . . .       ▶    3 
Schedule B                 Computation of Section 4953 Tax by the Person Making Excess Contributions Under Section 192 
                           to a Section 501(c)(21) Trust (See instructions)
1 a    Contributions made to section 501(c)(21) trust for operator’s tax year                  1a 
b      Operator’s maximum allowable deduction under section 192 for tax 
       year (enter amount from Schedule A, line 3)              .    .  . .      . .    .      1b 
c      Subtract line 1b from line 1a (if less than zero, enter -0-)              . .    .      1c 
2      Excess contributions carried over from the preceding tax year  .                          2 

3      Total (add lines 1c and 2)          .   .  . .       . . .    .  . .      . .    .    . .       .  . .   .      . . .    .       3 
4      Amount  that  current  year’s  contributions  are  less  than  the 
       maximum amount deductible (subtract line 1a from line 1b) (if less 
       than zero, 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 3)(if less than zero, enter -0-) .                      .       7 
8      Tax due (enter 5% of line 7). Pay in full with return.  .          .      . .    .    . .       .  . .   .      . . .   ▶        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
Please   ▲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. 
Sign  
Here                                                                                                                     Title 
                Signature of person filing return                                                           Date 
          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.
For Privacy Act and Paperwork Reduction Act Notice, see the back of the return.                                 Cat. No. 12145E             Form  6069  (Rev. 2-2012) 

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.