Form 990-Bl - Information And Initial Excise Tax Return For Black Lung Benefit Trusts And Certain Related Persons Page 2
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Form 990-BL (Rev. 12-2011)
Page
Questionnaire
Yes No
Part III
Have you made any changes not previously reported to the Internal Revenue Service in your governing instrument,
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or other similar instrument? .
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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?
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(2) Borrow or lend money or otherwise extend credit to (or accept it from) a disqualified person? .
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(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? .
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(4) Pay compensation to, or pay or reimburse expenses of, a disqualified person? .
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(5) Transfer any income or assets to, or for use by or for the benefit of, a disqualified person? .
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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? .
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c If the answer is “No” to question 23b, complete Schedule A (Form 990-BL), Part I, Section A.
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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?.
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If the answer is “Yes,” complete Schedule A, Form 990-BL, Part I, Section B.
Have you taken corrective action for any transaction that resulted in Chapter 42 taxes being reported on Schedule
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A, Form 990-BL?
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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.
$
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For any uncorrected acts, attach explanation (see instructions).
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Officers, directors, trustees and their compensation, if any, for the tax year:
(d)
(e)
(b)
(c) Contributions
(a)
Expense
Compensation
Title and time
to employee benefit
Name and Address
account, other
(If not paid,
devoted to position
plans
allowances
enter zero.)
Total .
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(Not open for public inspection)
Statement With Respect to Contributors, etc. —
Part IV
1
Persons who contributed $5,000 or more in the taxable year (if more space is needed, attach schedule):
Name
Address
Yes No
During the period covered by this return did the trust receive any contributions in excess of the maximum
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allowable deduction for the contributor under section 192?
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990-BL
Form
(Rev. 12-2011)
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