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

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Form 990-BL (Rev. 12-2011)
Page
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
(g) Initial tax on self-dealing disqualified person
(h) Tax on trustee (if applicable)
(f) Amount involved in act
(10% of column (f))
(2½% of column (f))
Total (add lines 1 through 4,
columns (g) and (h)) .
.
.
.
.
.
▶
SECTION B—Taxable Expenditures and Tax Computation (Section 4952)
(a) Item
(c) Date paid
(e) Description of expenditure and
(b) Amount
(d) Name and address of recipient
number
or incurred
purposes for which made
1
2
3
4
(h) Tax imposed on
(g) Tax imposed on trust
trustee (if applicable)
(f) Names of trustees liable for tax
(10% of column (b))
(2½% of column (b))
Total (Add lines 1 through 4, columns (g) and (h)) .
.
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▶
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
.
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3
Enter amount of section 4952 tax on trust from Part I, Section B, column (g) .
.
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3
4
Enter amount of section 4952 tax on trustee from Part I, Section B, column (h) .
.
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.
4
5
Total tax due (add lines 1 through 4) .
.
.
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5
▶
990-BL
Form
(Rev. 12-2011)

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