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Line 4. Enter the amounts contributed by the trust to the Federal Black

Attention: Entity Control, Stop 6273

Lung Disability Trust Fund as provided for by section 3(b)(3) of Public

Ogden, UT 84201-0027

Law 95-227.

Line 5. Enter the amounts paid for insurance exclusively covering

Inform them what numbers the trust has, the name and address to

liabilities under sections 501(c)(21)(A)(i)(I), and 501(c)(21)(A)(i)(IV). For

which each number was assigned, and the address of its principal office.

details, see Regulations section 1.501(c)(21)-1(d).

The IRS will then advise you which number to use.

Line 6. Enter the amounts paid to or for the benefit of miners or their

Application pending, address change, and FMV of assets. Fill in

beneficiaries other than amounts included in lines 4 or 5. Such payments

these blocks only when a return must be filed for a trust. Enter the fair

could include direct payment of medical bills, etc., authorized by the Act

market value (FMV) of the trust's assets at the beginning of the

and accident and health benefits for retired miners and their spouses

operator's tax year within which the trust's tax year begins.

and dependents.

Signature. The return must be signed by the authorized trustee or

Line 7. Enter the total amount of compensation for the year of all

trustees and also by any person, firm, or corporation who prepared the

trustees. See Part III, line 26.

return. If the return is prepared by a firm or corporation, it should be

signed in the name of the firm or corporation.

Line 8. Enter the total of the salaries and wages of all employees other

than those included in line 7.

Paid preparer. Generally, anyone who is paid to prepare the return

must sign the return and fill in the other blanks in the Paid Preparer Use

Line 9. Enter the administrative expenses (including legal, accounting,

Only area. An employee of the filing organization is not a paid preparer.

actuarial, and trustee expenses) for the year other than salaries and

wages paid to trustees and other employees.

The paid preparer must:

Sign the return in the space provided for the preparer's signature,

Line 10. Attach a schedule, listing by type and amount, all allowable

Enter the preparer information, and

deductions that are not deductible elsewhere on Form 990-BL. Enter the

Give a copy of the return to the organization.

total of these deductions on line 10. See Regulations section

The paid preparer must also enter the preparer's identifying number

1.501(c)(21)-1 for additional information.

and the firm's EIN. The preparer's identifying number is the preparer's

Part II—Balance Sheets

taxpayer identification number (PTIN).

Complete the balance sheets on the basis of the accounting method

Because the Form 990-BL is a publicly disclosable document,

regularly used by the trust in keeping its books and records.

any information entered in this block will be publicly disclosed

(see Public Inspection of Completed 990-BL Returns and

Line 19. Enter only liabilities of the trust as of the first and last days of

CAUTION

Approved Exemption Applications). Any paid preparer whose identifying

the tax year of the trust. Include payments for approved black lung

number must be listed on Form 990-BL can apply for and obtain a PTIN

claims that are due but not paid, accrued trustee fees, etc. Do not

using Form W-12, IRS Paid Preparer Tax Identification Number (PTIN)

include amounts for black lung claims being contested, the present value

Application and Renewal. For more information about applying for a

of payments for approved claims, or the estimated liability for future

PTIN online, visit the IRS website at IRS.gov/Ptin.

claims.

Line 21. Enter the total of lines 19 and 20. That figure must equal the

Paid preparer authorization. On the last line of the Signature Block,

check “Yes,” if the IRS can contact the paid preparer who signed the

figure for total assets reported on line 18 for both the beginning and end

of year.

return to discuss the return. This authorization applies only to the

individual whose signature appears in the Paid Preparer Use Only

Part III—Questionnaire

section of Form 990-BL. It does not apply to the firm, if any, shown in that

section. By checking “Yes,” to this box, the organization is authorizing

the IRS to contact the paid preparer to answer any questions that arise

General Instructions

during the processing of the return.

The Black Lung Benefits Revenue Act of 1977 imposes excise taxes and

The organization is also authorizing the paid preparer to:

penalties on acts of self-dealing between trusts and disqualified persons,

Give the IRS any information missing from the return;

and on taxable expenditures made by the trusts. These taxes and

Call the IRS for information about processing the return; and

penalties apply to the trust (section 4952), trustees (sections 4951 and

Respond to certain IRS notices about math errors, offsets, and return

4952), and self-dealers (section 4951). The purpose of the questions is

preparation.

to determine whether there is any initial tax due under either of these two

The organization is not authorizing the paid preparer to bind the

sections.

organization to anything or otherwise represent the organization before

Definitions

the IRS.

The authorization will automatically end no later than the due date

Self-dealing (Section 4951)

(excluding extensions) for filing the Form 990-BL. If the organization

wants to expand the paid preparer’s authorization or revoke it before it

Self-dealing. For purposes of section 4951, the term “self-dealing”

ends, see Pub. 947, Practice Before the IRS and Power of Attorney.

means any direct or indirect:

Check “No,” if the IRS should contact the organization or its trustee

Sale, exchange, or leasing of real or personal property between a

rather than the paid preparer.

trust described in section 501(c)(21) and a disqualified person;

Lending of money or other extension of credit between such a trust

Part I—Analysis of Revenue and

and a disqualified person;

Expenses

Furnishing of goods, services, or facilities between such a trust and a

disqualified person;

Payment of compensation (or payment or reimbursement of

Line 1. Enter the total contributions received under section 192 from the

expenses) by such a trust to a disqualified person; and

coal mine operator who established the trust.

Transfers to, or use by or for the benefit of, a disqualified person of

Contributions to the trust must be in cash or property of the type in

the income or assets of such a trust.

which the trust is permitted to invest (i.e., public debt securities of the

Special rules. For purposes of section 4951:

United States, obligations of a state or local government that are not in

The transfer of personal property by a disqualified person to such a

default as to principal or interest, or time and demand deposits in a bank

trust is treated as a sale or exchange if the property is subject to a

or insured credit union as described in section 501(c)(21)(D)(ii)).

mortgage or similar lien;

Line 2. Enter the amounts received during the year from the sources

If a bank or an insured credit union is a trustee of the trust or

listed in 2a, b, c, and d.

otherwise is a “disqualified person” with respect to the trust, any amount

invested in checking accounts, savings accounts, certificates of deposit,

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Instructions For Form 990-Bl - Information And Initial Excise Tax Return For Black Lung Benefit Trusts And Certain Related Persons Page 3

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